Ocular changes after accidental exposure to distilled water: A case series

Pooja Karki; Chandra M Gurung; Archana Sharma; Ayush Joshi; Priya Bajgai

doi:10.4103/ijo.IJO_1617_21

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CASE REPORT

Year : 2022 | Volume : 2 | Issue : 2 | Page : 348-352

Ocular changes after accidental exposure to distilled water: A case series

Pooja Karki¹, Chandra M Gurung¹, Archana Sharma¹, Ayush Joshi², Priya Bajgai¹
¹ Department of Ophthalmology, Nepal Eye Hospital, Tripureswor, Kathmandu, Nepal
² Department of Biomedical Engineering, Nepal Eye Hospital, Tripureswor, Kathmandu, Nepal

Date of Submission	10-Jun-2021
Date of Acceptance	28-Oct-2021
Date of Web Publication	13-Apr-2022

Correspondence Address:
Priya Bajgai
Assistant Professor, Nepal Eye Hospital, Kathmandu
Nepal

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1617_21

Abstract

We report ocular changes following accidental injection of distilled water into the anterior chamber during cataract surgery. We have documented eight eyes that had an accidental distilled water exposure in the anterior chamber following which they developed corneal edema, raised intraocular pressure (IOP), and pigment dispersion into the anterior chamber. We treated all the patients with topical steriods and sodium chloride 5% solution and anti-glaucoma medications as required. All of them had pigment dispersion and deposition into the anterior chamber and onto the corneal endothelium and the intraocular lens surface. All the patients had resolution of edema and good vision postoperatively after a month. Thus, patients who were exposed to accidental injection of distilled water into the anterior chamber during cataract surgery had a toxic reaction in the postoperative period. However, the corneal transparency was restored completely without complications with adequate treatment. A strict protocol must be followed by the OT staff and the members at various stages of surgery to prevent such mishaps from happening.

Keywords: Cataract surgery, corneal edema, distilled water, sodium chloride solution

How to cite this article:
Karki P, Gurung CM, Sharma A, Joshi A, Bajgai P. Ocular changes after accidental exposure to distilled water: A case series. Indian J Ophthalmol Case Rep 2022;2:348-52

How to cite this URL:
Karki P, Gurung CM, Sharma A, Joshi A, Bajgai P. Ocular changes after accidental exposure to distilled water: A case series. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2023 Mar 29];2:348-52. Available from: https://www.ijoreports.in/text.asp?2022/2/2/348/342893

An essential component of an ocular surgical procedure is a safe irrigating solution. However, any irrigating solution used inside the eye has the potential to damage the ocular structures. Many solutions, such as distilled water, are not formulated for intraocular use and may damage vital structures such as the endothelium. Distilled water is a transparent and odorless fluid that is widely used in operation theatres to clean surgical instruments. Because of its nature, it may be difficult for surgical personnel to distinguish distilled water from normal saline or balanced salt solution (BSS). There is always a risk that the distilled water will be loaded into a syringe, and there have been reports of corneal endothelial damage resulting from the inadvertent infusion of distilled water during cataract surgery.^{[1],[2],[3],[4]} As distilled water is very hypotonic, has 0 osmolality, and has no protective ion composition, buffering capacity, or antioxidant properties for intraocular tissues, unlike aqueous humor or BSS, intraocular infusion of distilled water may damage intraocular tissues, including the corneal endothelium and the iris tissues. Intraocular infusion of distilled water may also affect the lens of a phakic eye. There have been a few cases of accidental injection of distilled water into the anterior chamber during various surgical procedures such as refractive surgeries or cataract surgeries where it resulted in reversible cataract and corneal edema.^[2],[3] Some cases have been reported wherein the accidental injection of distilled water into the AC resulted in corneal edema postoperatively, which was managed with topical steroids.^[2],[4] Herein, we report eight cases of accidental injection of distilled water into AC which resulted in severe corneal edema with raised IOP in two eyes requiring oral and topical steroids and antiglaucoma medications. All the cases had pigments dispersed into the AC and onto the endothelium and the IOL surface. However, all the cases restored corneal transparency, and IOP was controlled conservatively. There have been no reports on such a large number of cases being affected on the same day, how each case was managed with appropriate medications, and all resulting in a favorable outcome.

Case Series

Eight eyes of eight patients were accidentally exposed to distilled water during routine cataract surgery at Nepal Eye Hospital, Kathmandu. Following the incident, during the immediate postoperative period, each case had a varied clinical presentation which was probably related to the amount of distilled water exposed, the preexisting corneal endothelial status, and the degree of cataract [Table 1].

Table 1: Findings preoperatively and post-distilled water instillation of patients undergoing cataract surgery (Post-op Day 1, Day 7, and Day 30)

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There were three females and five males; the mean age was 68.4 years (range: 59–78 years). All were operated on the same day. The average preoperative visual acuity was logMAR 1.49 ± 0.39, and the IOP was 12.8 mm Hg. All the patients underwent cataract surgery by the phacoemulsification technique with implantation of the intraocular lens (IOL) in the bag. The other intraoperative events were uneventful. At the end of the surgeries, the surgeon noted that the bottles used were all transparent and that odorless distilled water instead of the normal routine solutions had been used. We admitted all the patients and asked for history of any excessive pain during the immediate postoperative period. We did not attempt any type of AC wash or other immediate measures out of desperation as we routinely give a subconjunctival injection of dexamethasone to all the patients. Thus, all the patients were evaluated on day 1 of the postoperative period, and each case management was individualized. Those with a lesser degree of corneal edema were managed with topical steroids as per the amount of edema and frequent 5% sodium chloride drops along with the routine antibiotics. [[Figure 1], Cases 1–3, [Table 1]] However, out of the eight cases, three cases had a slightly more severe form of corneal edema along with the raised IOP. We will be discussing two such cases in detail here.

Figure 1: Anterior segment photograph of (Case 1) on immediate postoperative day 1 after exposure to distilled water (a) and its resolution after 1 week of conservative management (b). Pigmentary deposits on the anterior lens surface even after recovery. (c) Anterior segment photograph on day 1 (d), on day 7 (e), and on 1 month (f) after distilled water exposure (Case 2). Anterior segment photograph on day 1 and day 7 after exposure to distilled water (Case 3) (g-h)

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Case 4

A 62-year-old male patient with a preoperative visual acuity of 3/60 in the right eye and cataract of nuclear opacity grade III (LOCS classification) was operated at our institute. He was accidentally exposed to irrigating solution in the form of distilled water during the surgery. The OT nursing staff was a newly recruited person and the identification of the bottle was mistaken as it is also odorless and transparent like the other irrigating solutions and they were all placed together in the storeroom. The surgeon noted that at the end of the surgery, the cornea was a bit more cloudy as compared to the other days and asked for the matter to be addressed. Then, the accidental distilled water injection into AC was discovered. We inject subconjunctival injection of dexamethasone to all the cases routinely; thus, we admitted the patient and evaluated him on postoperative day 1. He had vision of hand motions close to face with an IOP of 40 mm Hg measured by a Goldmann Applanation tonometer. The cornea was cloudy with epithelial bullae, stromal edema, and Descemet's membrane folds. The endothelium contained plenty of pigmentary deposits, and the anterior segment detail was unclear. We started the patient on frequent topical 0.1% prednisolone acetate (every 30 min), topical 5%Nacl (6–8 times per day), and Gtt Ofloxacin six times per day. We also added antiglaucoma medications in the form of oral acetazolamide 250 mg tablet (2 tab stat and TDS). He was re-evaluated after 6 h, and his IOP had decreased to 24 mm Hg and the corneal epithelial bullae had decreased. We continued the same and saw the patient after a week after decreasing his dosage of topical medications gradually [[Figure 2], CASE #4, [Table 1]]. His uncorrected visual acuity after 1 week was 6/60, IOP was 20 mm Hg, and his cornea was clearer with a visible anterior segment. We could see a few DM folds and pigmentary deposits both on the corneal endothelium and on the IOL surface. We further tapered the dosage of the topical medications and asked the patient to come after a month. He visited after 2 weeks with complaints of ocular congestion and pain. On evaluation, he had a large epithelial defect without any infiltrates which was managed with eye padding and topical medications. The defect gradually healed without any secondary infection. Thus, the patient had a clear cornea and a controlled IOP with postoperative visual gain.

Figure 2: Anterior segment photograph of (Case 4) on day 1 and day 7 of distilled water exposure (a and b). Epithelial defect (c and d) after 2 weeks of exposure which later healed. Pigmentary deposits on the corneal endothelium (e). Anterior segment photograph of (Case 5) who developed edema with raised IOP and corneal endothelial pigmentation on postoperative day 1 (f and g) which decreased after 1 week of conservative management (h and i)

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Case 5

A 73-year-old male patient with a best-corrected visual acuity of 6/60 in the left eye with nuclear opacity grade III (LOCS III classification) underwent cataract surgery at our hospital and was exposed to accidental distilled water injection on the same day as the rest of the cases. On postoperative day 1, he had vision of hand motions close to the face with an IOP of 38 mm Hg GAT. His cornea was hazy with epithelial bullae, stromal edema, and DM folds with pigments on the endothelial surface. The anterior segment details were not clear. He was treated with frequent topical steroids (0.1% predacetate half-hourly), 5% NaCl (6–8 times per day), Gtt Ofloxacin, and oral acetazolamide 250 mg (2 tablet stat and TDS for 3 days). He was evaluated after a few hours, and his IOP was controlled with a clearer anterior segment detail. We continued the same medication for a week and on evaluation, he had an uncorrected visual acuity of 1/60 with decreased but persisting edema (picture) [[Figure 2], Case 5]. He eventually lost to follow up; thus, we do not have the final outcome for the patient. This case shows us the importance of prompt management of such cases with adequate oral and topical medications which lead to prompt resolution of the corneal edema.

Discussion

Various reports have shown that postoperative corneal edema can be caused by mechanical or chemical injuries to the corneal endothelium, which further depends on the ocular medications and surgical solutions used. Any type of solution used within the eye has the potential to damage the intraocular structures.^{[5],[6],[7],[8],[9],[10],[11]} An ideal irrigating solution should contain an energy source, an adequate buffer, and a substrate to maintain the blood–aqueous barrier. The pH of the solution should be between 6.7 and 8.1, with an osmolality of 270 and 350, to maintain the endothelial structure. Many solutions and drugs are not formulated for intraocular use and contain preservatives, vehicles, and solubilizers that can damage the corneal endothelium.

A total of eight eyes were accidentally exposed to distilled water during routine cataract surgery. To our knowledge, this is the first case in which a total of eight cases were affected on the same day and all of them recovered with the clearing of corneal clouding in the end. We also noted raised IOP in three cases which was successfully managed conservatively. Similarly, there were pigmentary deposits on the corneal endothelium, in the anterior chamber, and onto the IOL surface which was visualized when the edema subsided. This might be due to the effect of the distilled water on the iris tissue, leading to its shedding and pigment dispersion. The severity of the corneal damage was probably limited in all our cases by the following factors: i) corneal endothelial status of the patients; ii) wash out of the distilled water by the intracameral antibiotics, which we routinely inject at the end of the surgery; and iii) by the subconjunctival injection of dexamethasone at the end of the cataract surgery. The average visual acuity preoperatively was logMAR 1.48 ± 0.42, which improved to logMAR 0.66 ± 0.30 at the end of 1 month (P = 0.01, by paired t test, and it was statistically significant). Although we routinely use sterile ringer lactate glass bottle solutions for intraocular surgical procedures, on this particular day of surgery, the glass bottles were finished and we had to use plastic ringer lactate bottles for the procedure, and because they were placed together with the distilled water bottles in the storage place, the OT assistant, who was new, mistakenly held up these bottles for the surgery. It was only later during one of the cases when the cornea was cloudy and the surgeon asked for the check of the bottles that it was discovered that the bottles mishap had taken place. The rest of the surgeries were carried out carefully with proper placement of the right ringer lactate bottles later on. Thus, it is always important on part of the OT personnel and the surgeon to carefully check all solutions that are going to be used during surgery, to prevent such occurrences. One may also consider placing the harmful irrigating solutions away from the useful intraocular solutions in the storage rooms with proper labeling.

Human endothelium can tolerate osmolalities up to a level of 200 mOsm before endothelial cell breakdown is evident. Endothelial cell death was seen when the bovine endothelial culture was exposed to distilled water for 5 min.^[6] Similarly, Grimmett et al.^[1] noted that after accidental injection of distilled water into the eye during miochol injection, there was rapid clouding of the cornea which, however, resolved later on. They further studied the effect of irrigation of distilled water into human and rabbit eyes and observed that the corneal thickness increased rapidly. Electron microscopy showed prominent ultrastructural alterations of the endothelium after exposure to water. Their problem occurred due to the failure to understand the plunger mechanism, leading to accidental injection into the anterior chamber during the surgery.

Conclusion

In conclusion, corneal edema that developed after intracameral exposure to distilled water was reversible. Because significant damage to the corneal endothelium can occur, surgeons should always pay special attention to the intraocular infusion fluid and check the original bottle. There should be a strict protocol in the operation theatre and awareness amongst the OT staff and members to understand the harmful effects of such mishaps. The bottles should be placed in separate sections and properly labeled. If distilled water is inadvertently infused, surgeons should promptly manage with frequent topical steroids, NaCl solution, and anti-glaucoma medications as needed. Some have advocated irrigation with a solution such as BSS which might be attempted in cases of massive edema instantaneously. In addition, surgeons should perform sufficient follow-up of the patients to watch out for any other complications that might arise.

Authors contribution

PB and PK managed the patients and formatted the manuscript. The rest of the authors read and approved the final manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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