In our institution, all cataract surgeries are performed in the ambulatory center. Patients are asked to complete a health questionnaire, and most of them are seen for a preoperative evaluation. Patients may or may not be asked to fast prior to surgery, depending on the surgeon. Usual medications, including anticoagulants, are continued. An intravenous line is placed on arrival and an anesthesiologist (assistant or nurse anesthesiologist always supervised by a senior) is present in the operating room.

The first patient was an 81-year-old woman classified per the American Society of Anesthesiologists (ASA) Physical Status Classification System as ASA II due to hypothyroidism, hypertension, pulmonary embolism, gastric ulcer, and hepatitis B. She had no history of allergy. She underwent an uncomplicated cataract surgery for the first eye on September 7, 2020, and she presented 2 weeks later for the second eye. According to her surgeon, she did not fast. The surgery was performed uneventfully and no intervention by the anesthesiologist was necessary. Postoperatively, while escorting the patient toward her room, she complained of chest pain and discomfort before falling unconscious with urinary incontinence. Blood pressure (BP) and heart rate (HR) were measured at 40/20 mmHg and 140 beats per minute, respectively. She was immediately managed by the anesthetic team by orotracheal intubation, intravascular filling and norepinephrine support. She was then admitted to the intensive care unit (ICU) where she was noted to have palpebral and labial edema and lower limbs rashes. After 24 h, the vasopressor support was weaned, and the patient was extubated; she was discharged the following day with a 7-day course of antibiotics for a suspected aspiration pneumonia as she did no fast. Serum Tryptase, a specific marker for anaphylaxis, was significantly increased. An anaphylactic shock due to a substance received during the surgery was suspected. Therefore, three months later she underwent cutaneous allergic tests in day hospital close medical supervision and all medications used during surgery were tested. She rapidly developed another anaphylactic shock, which was treated effectively by epinephrine and corticosteroids. An allergy to cefuroxime was confirmed. This antibiotic is administered intraocularly at the end of each cataract surgery to prevent endophthalmitis, and we believe that sensitization to this molecule occurred during the first surgery leading to anaphylactic shock at the second operation.

The second patient was a 77-year-old healthy woman classified as ASA II due to hypothyroidism and rhizomelic pseudo-polyarthritis treated with 4 mg methylprednisolone (Medrol). She had no history of allergy. Cataract surgery for the first eye was performed three weeks before, without any complications, and she presented for the second eye. According to her surgeon, she fasted. The surgery completed without complication and she was escorted to her room where she received a light meal before leaving. Thirty minutes after surgery she felt discomfort with nausea. BP was 60/30 mmHg and HR was 30 per minute. Atropine (0.25 mg) was administered through the intravenous line and her BP and HR increased to 90/50 mmHg and 80 per minute, respectively. She was admitted in the Postoperative Acute Care Unit where she developed vomiting, agitation, and a sudden desaturation to 88% under 6 L of oxygen while BP and HR normalized. Her chest radiograph showed a small right perihilar infiltrate. A chest CT with contrast was performed, which revealed bibasal pneumonitis. COVID-19 investigations were negative. Cardiac echography was normal. After a few hours of noninvasive ventilation, she recovered and oxygen saturation normalized. She fully recovered and was discharged 3 days later. Serum Tryptase was not significantly high but unfortunately, the patient did not wish to perform any other tests to confirm the anaphylactic reaction hypothesis.