we describe a case of transient visual loss following cataract surgery with unpreserved intracameral lidocaine . a 50-year - old man with posterior polar cataract underwent phacoemulsification . following capsulorhexis and hydrodelineation with 0.5  cc of unpreserved lidocaine 1% , a portion of fluid reached behind the crystalline lens and caused the posterior capsule rupture . cataract extraction and anterior vitrectomy were performed . on the first postoperative morning , the patient 's vision was recorded as having no light perception . the retina and optic nerve head appeared normal . in the afternoon , the visual acuity ( va ) was improved to 3-m count - finger . on the second postoperative morning , the patient 's va was improved to 4/10 . on the third postoperative day in the event of posterior capsular rupture , to reduce retinal toxicity risks , intracameral lidocaine should not be repeated . using unpreserved intracameral lidocaine as an adjunct anesthetic to topical anesthesia has become a widespread technique in cataract surgery . while safety and efficacy of intracameral lidocaine is well - documented , retinal toxic effects and transient visual loss caused by lidocaine have been suggested . we report a case of transient , complete visual loss , following posterior polar cataract surgery with posterior capsular rupture . a 50-year - old man presented to our clinic complaining of blurred vision for one year in his right eye . his intraocular pressure and other ocular examinations including relative afferent pupillary defect ( rapd ) were unremarkable . following capsulorhexis and hydrodelineation with 0.5 cc - unpreserved lidocaine 1% , a portion of fluid reached behind the crystalline lens and caused the posterior capsule rupture . a three - piece hydrophobic acrylic ( hoya )  intraocular lens ( iol ) was placed in the ciliary sulcus . at the conclusion of surgery , the eye was patched , and the patient was discharged . on the first post - operative morning , the patient complained of not being able to see anything . the retina appeared normal , and the optic disc was not edematous . in the afternoon , the patient 's visual acuity ( va ) was improved to 3-m count - finger . on the second postoperative morning , the patient 's va was improved to 4/10 . the patient 's va had improved to 20/20 without rapd , and all other ocular examinations were normal . the preferred technique for cataract surgeons in the united states is topical anesthesia ( 37% ; range 2263% ) . in a survey conducted by david learning , lidocaine is a useful adjunct , particularly in cases involving pupillary manipulation and peripheral iridectomy . while lidocaine has been reported to be safe and effective,2 , 3 temporary visual loss4 , 5 , 6 and retinal toxicity4 , 6 following the use of intracameral lidocaine have been highlighted in recent reports . an increased possibility of adverse effects of lidocaine on the retina and optic nerve is introduced in the event of compromise to the posterior lens capsule . our patient had experienced transient visual loss while receiving intracameral lidocaine and had an associated posterior capsule rupture , which has an incidence of between 26% and 36% in posterior polar cataract surgeries.7 , 8 normally , during cataract surgery , the lens capsule , zonules , and vitreous humor have a barrier effect against instilled intracameral lidocaine , and hence , the retina will not be affected . pars plana lensectomy and vitrectomy facilitate the diffusion of the lidocaine into the posterior chamber . reported amaurosis in four patients following the use of intracameral lidocaine , and in each case , the posterior capsule was not intact . hoffman and fine reported on a patient with complete visual loss after intracameral lidocaine to repair a traumatic corneal graft dehiscence with a capsular tear , which was fully recovered several hours postoperatively . reported a case of transient , complete loss of vision following phacoemulsification with an intracameral ophthalmic viscosurgical device ( ovd ) and lidocaine solution complicated by posterior capsule rupture , which improved to 20/80 after one day and 20/25 in one week . full recovery of visual acuity in our patient required three days , in contrast to the majority of reports ( table 1 ) with capsular tear4 , 9 that had complete va improvements within hours . the longer time span in recovery of va in our patient might be explained by a higher volume of lidocaine that was diffused in the vitreous . reported three cases of inadvertent intravitreal lidocaine injections , all of which resulted in immediate decreased vision , with recovery occurring within four hours . schechter reported a case of inadvertent intraocular lidocaine injection with an immediate visual acuity of nlp ( no light perception ) that improved to 20/40 after one day and to 20/20 in one week . this inhibition is probably due to an anesthetic - induced disruption of intercellular ionic balance and increased plasma membrane permeability . furthermore , intravitreal injection of lidocaine has also been investigated in cats , rabbits , and rats.6 , 12 , 13 in these animal studies , the electroretinogram analyses revealed a reversible reduction in the amplitude and extinguished b - waves which fully recovered within 1024  h. in cats , intravitreal injection of lidocaine has been followed with vacuolization of nerve layers and presence of microscopic lesions in synapses between horizontal , bipolar cells , and photoreceptors . one limitation of our study is that the patient did not consent to perform the erg and mferg tests . however , in the presence of positive rapd , normal retinal examination , and full recovery of vision , the most plausible cause of vision loss would be attributed to lidocaine retinal toxicity . in view of the above , when posterior capsular rupture occurs , it is wise not to repeat intracameral lidocaine to minimize potential retinal toxicity risks . the authors have no financial or proprietary interest in a product , method , or material described herein .
purposewe describe a case of transient visual loss following cataract surgery with unpreserved intracameral lidocaine.methoda 50-year - old man with posterior polar cataract underwent phacoemulsification . following capsulorhexis and hydrodelineation with 0.5  cc of unpreserved lidocaine 1% , a portion of fluid reached behind the crystalline lens and caused the posterior capsule rupture . 
 cataract extraction and anterior vitrectomy were performed . 
 anesthetic administration was repeated to relieve the discomfort felt by the patient . 
 a three - piece hydrophobic acrylic intraocular lens was implanted in the ciliary sulcus.resultson the first postoperative morning , the patient 's vision was recorded as having no light perception . 
 the relative afferent pupillary defect ( rapd ) was found to be 4 + . 
 the retina and optic nerve head appeared normal . in the afternoon , the visual acuity ( va ) was improved to 3-m count - finger . 
 on the second postoperative morning , the patient 's va was improved to 4/10 . on the third postoperative day 
 , his va returned to normal at 20/20 without rapd.conclusionin the event of posterior capsular rupture , to reduce retinal toxicity risks , intracameral lidocaine should not be repeated .