Toxic Anterior Segment Syndrome: Inadvertent Administration of Intracameral Lidocaine 1% and Phenylephrine 2.5% Preserved With 10% Benzalkonium Chloride During Cataract Surgery

Cornea. 2017 May;36(5):621-624. doi: 10.1097/ICO.0000000000001145.


Purpose: To report 3 patients with corneal decompensation and anterior uveitis within 24 hours of cataract surgery from a single ambulatory surgery center using intracameral lidocaine HCl 1% and phenylephrine 2.5% inadvertently preserved with 10% benzalkonium chloride.

Methods: This case series describes 3 patients who underwent traditional cataract extraction with a significant decrease in visual acuity in the immediate postoperative period resulting in secondary surgical intervention for corneal decompensation in 2 patients.

Results: All 3 patients experienced a dramatic decrease in visual acuity on the day of surgery, ranging from 20/400 to light perception. They were treated with topical steroids and sodium chloride, with stabilization of vision at 20/60 in 1 patient. The remaining 2 patients did not recover with medical management. One underwent Descemet stripping automated endothelial keratoplasty with placement of the corneal graft on top of Descemet membrane, which could not be removed secondary to extensive fibrosis. The third patient underwent penetrating keratoplasty secondary to deep corneal scarring.

Conclusions: This is the first case series of toxic anterior segment syndrome occurring secondary to the use of benzalkonium chloride-preserved intracameral lidocaine and phenylephrine. Clinicians should remain alert to this phenomenon, and should refrain from using intracameral preservatives during cataract surgery.

Publication types

  • Case Reports

MeSH terms

  • Aged
  • Aged, 80 and over
  • Anesthetics, Local / administration & dosage
  • Anesthetics, Local / adverse effects*
  • Benzalkonium Compounds / administration & dosage
  • Benzalkonium Compounds / adverse effects*
  • Corneal Edema / chemically induced*
  • Female
  • Humans
  • Lidocaine / administration & dosage
  • Lidocaine / adverse effects*
  • Male
  • Medical Errors / adverse effects*
  • Middle Aged
  • Mydriatics / administration & dosage
  • Mydriatics / adverse effects*
  • Phenylephrine / administration & dosage
  • Phenylephrine / adverse effects*


  • Anesthetics, Local
  • Benzalkonium Compounds
  • Mydriatics
  • Phenylephrine
  • Lidocaine