Acquired retinal toxicity following ocular surgery and pharmacotherapy: mechanisms and clinical implications Review article
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Published:
Jul 16, 2026
Keywords:
retinal toxicity, phototoxicity, vitreoretinal surgery, intravitreal drugs, hydroxychloroquine retinopathy
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Abstract
Acquired retinal toxicity represents an important and potentially vision-threatening complication of medical therapies, surgical procedures and environmental exposures. It may result from phototoxic injury, intraocular dyes, intravitreal medications or long-term systemic drug use. Advances in retinal imaging have improved early detection. However, retinal damage is often irreversible once established. Understanding the mechanisms, risk factors, and clinical manifestations of retinal toxicity is essential for prevention, timely diagnosis and optimal patient management. This review summarizes the main mechanisms of acquired retinal toxicity, illustrates them with representative clinical cases and discusses current strategies for prevention and management.
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1.
Malon P, Bych A, Konczyński S, Kaźmierczak K. Acquired retinal toxicity following ocular surgery and pharmacotherapy: mechanisms and clinical implications. Ophthatherapy [Internet]. 2026Jul.16 [cited 2026Jul.26];00:A0010. Available from: https://www.journalsmededu.pl/index.php/ophthatherapy/article/view/3437
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Surgery and laser therapy
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Address reprint requests to: Medical Education, Marcin Kuźma (marcin.kuzma@mededu.pl)
References
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19. Abdouh M, Chen Y, Goyeneche A et al. Blue Light-Induced Mitochondrial Oxidative Damage Underlay Retinal Pigment Epithelial Cell Apoptosis. Int J Mol Sci. 2024; 25(23): 12619. http://doi.org/10.3390/ijms252312619.
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21. Bacsal KM, Chee SP. Trypan blue-associated retinal toxicity post complicated cataract surgery. Eye (Lond). 2006; 20(11): 1310-1. http://doi.org/10.1038/sj.eye.6702164.
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23. Pastor JC, Coco RM, Fernandez-Bueno I et al. Acute retinal damage after using a toxic perfluoro-octane for vitreo-retinal surgery. Retina. 2017; 37(6): 1140-51. http://doi.org/10.1097/IAE.0000000000001680.
24. Veritti D, Lanzetta P, Bandello F et al. Viscoelastic agent retention and failed macular hole surgery. Retin Cases Brief Rep. 2009; 3(1): 77-9. http://doi.org/10.1097/ICB.0b013e318158de4f .
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26. Pichi F, Hay S, Abboud EB. Inner retinal toxicity due to silicone oil: a case series and review of the literature. Int Ophthalmol. 2020; 40(9): 2413-22. http://doi.org/10.1007/s10792-020-01418-0.
27. Kumoi M, Matsuda S, Matsumoto M et al. Toxic posterior segment syndrome caused by silicone oil tamponade resulting in postsurgical retinal vascular occlusion: a case report. Am J Ophthalmol Case Rep. 2025; 39: 102404. http://doi.org/10.1016/j.ajoc.2025.102404.
28. Muuss M, Karaivanova M, Skrzypczyk L et al. F4H5 Alleviates Increased Outflow Resistance Induced by Emulsified Silicone Oil In Vitro. Invest Ophthalmol Vis Sci. 2025; 66(11): 21. http://doi.org/10.1167/iovs.66.11.21.
29. Karakosta C, Downes SM. Progressive Retinal Toxicity Nine Years After Hydroxychloroquine Discontinuation: A Case Report. Cureus. 2025; 17(12): e98674. http://doi.org/10.7759/cureus.98674.
30. Eldeeb M, Chan EW, Omar A. Case Report: Hydroxychloroquine Retinopathy. Optom Vis Sci. 2018; 95(6): 545-9. http://doi.org/10.1097/OPX.0000000000001226.
31. Bertagnolio S, Tacconelli E, Camilli G et al. Case report: Retinopathy after malaria prophylaxis with chloroquine. Am J Trop Med Hyg. 2001; 65(5): 637-8. http://doi.org/10.4269/ajtmh.2001.65.637.
32. Souza Monteiro de Araújo D, Brito R, Pereira-Figueiredo D et al. Retinal Toxicity Induced by Chemical Agents. Int J Mol Sci. 2022; 23(15): 8182. http://doi.org/10.3390/ijms23158182.
33. Lin RC, Cantrill HL, Mieler WF. Retinal Toxicities Caused by Systemic Medications. Retinal Physician. 2007; November/December 2007.
34. Bonting SL, Caravaggio LL, Canady MR. Studies on sodium potassium-activated adenosine triphosphatase. X Occurrence in retinal rods and relation to rhodopsin Exp Eye Res. 1964; 3: 47-56.
35. McDonald HR, Schatz H, Allen AW et al. Retinal toxicity secondary to intraocular gentamicin injection. Ophthalmology. 1986; 93(7): 871-7. http://doi.org/10.1016/s0161-6420(86)33648-0.
36. Almeida LN, Canêdo MG, Almeida RN et al. Maculopatia isquêmica após injeção intravítrea de amicacina: relato de caso Macular infarction after intravitreal injection of amikacin: case report. Arq Bras Oftalmol. 2005; 68(6): 837-40. http://doi.org/10.1590/s0004-27492005000600023.
37. Doft BH, Barza M. Macular infarction after intravitreal amikacin. Br J Ophthalmol. 2004; 88(6): 850. http://doi.org/10.1136/bjo.2003.038885.
38. Hernández Pardines F, Tapia-Quijada H, Hueso-Abancens JR. A case of aminoglycosides induced retinal toxicity treated with megadoses of steroids and an intravitreal dexamethasone implant (Ozurdex(®)). Arch Soc Esp Oftalmol. 2016; 91(6): 288-91. http://doi.org/10.1016/j.oftal.2016.01.017.
39. Muid J, Awan MA. Haemorrhagic occlusive retinal vasculitis caused by intravitreal vancomycin. J Pak Med Assoc. 2020; 70(9): 1648-50. http://doi.org/10.5455/JPMA.46528.
40. Ksiazek S, Grover S, Mojica G et al. Indocyanine green toxicity of the retina after cataract surgery: a case report. Retin Cases Brief Rep. 2009; 3(2): 115-7. http://doi.org/10.1097/ICB.0b013e318162b123.
41. Yeh LK, Yang CS, Lee FL et al. Solar retinopathy: a case report. Zhonghua Yi Xue Za Zhi (Taipei). 1999; 62(12): 886-90.
42. McDonald HR, Harris MJ. Operating microscope-induced retinal phototoxicity during pars plana vitrectomy. Arch Ophthalmol. 1988; 106(4): 521-3. http://doi.org/10.1001/archopht.1988.01060130567038.
43. Witkin AJ, Chang DF, Jumper JM et al. Vancomycin-Associated Hemorrhagic Occlusive Retinal Vasculitis: Clinical Characteristics of 36 Eyes. Ophthalmology. 2017; 124(5): 583-595. http://doi.org/10.1016/j.ophtha.2016.11.042.
44. Hsu ST, Ponugoti A, Deaner JD et al. Update on Retinal Drug Toxicities. Curr Ophthalmol Rep. 2021; 9(4): 168-77. http://doi.org/10.1007/s40135-021-00277-x .
45. Hydroxychloroquine Toxicity. Weng CY, Kim JE, Leng T et al (eds.). EyeWiki, San Francisco 2025.
46. Wang G, Zhuo N, Liao Z et al. Retinal toxicity caused by hydroxychloroquine in patients with systemic lupus erythematosus: A case report. Medicine (Baltimore). 2021; 100(22): e25688. http://doi.org/10.1097/MD.0000000000025688.
47. Ding HJ, Denniston AK, Rao VK et al. Hydroxychloroquine-related retinal toxicity. Rheumatology (Oxford). 2016; 55(6): 957-67. http://doi.org/10.1093/rheumatology/kev357.
48. Pereira C D R, Miguel V S, Miguel TS et al. Early and progressive hydroxychloroquin retinal toxicity: 9-year follow-up with multimodal retinal imaging. Int J Med Ophthalmol. 2022; 4(2): 9-14. http://doi.org/10.33545/26638266.2022.v4.i2a.120.
2. Yang X, Shao D, Ding X et al. Chronic phototoxic maculopathy caused by welding arc in occupational welders. Can J Ophthalmol. 2012; 47(1): 45-50. http://doi.org/10.1016/j.jcjo.2011.12.001.
3. Robertson DM, Lim TH, Salomao DR et al. Laser pointers and the human eye: a clinicopathologic study. Arch Ophthalmol. 2000; 118(12): 1686-91. http://doi.org/10.1001/archopht.118.12.1686.
4. Nazari T, Jalink MB. Central scotoma following phacoemulsification surgery: A case report on retinal phototoxicity. Am J Ophthalmol Case Rep. 2025; 38: 102334. http://doi.org/10.1016/j.ajoc.2025.102334.
5. Ruiz-Moreno JM, García-Zamora M, Ruiz-Medrano J. Retinal phototoxicity after macular hole surgery in a patient under paclitaxel. BMC Ophthalmol. 2023; 23(1): 342. http://doi.org/10.1186/s12886-023-03086-x.
6. Hofstra LS, de Vries EG, Willemse PH. Ophthalmic toxicity following paclitaxel infusion. Ann Oncol. 1997; 8(10): 1053. http://doi.org/10.1023/a:1008249230056.
7. Malcolm J, Lune Wong CO et al. Paclitaxel may be a risk factor for retinal phototoxicity. Am J Ophthalmol Case Rep. 2022; 25: 101292. http://doi.org/10.1016/j.ajoc.2022.101292.
8. American Academy of Ophthalmology. Solar Retinopathy. Section 12: Retina and Vitreous. Basic and Clinical Science Course, 2025-2026. San Francisco, CA.
9. Stock RA, Savaris SL, de Lima Filho EC et al. Solar retinopathy without abnormal exposure: case report. Arq Bras Oftalmol. 2013; 76(2): 118-20. http://doi.org/10.1590/s0004-27492013000200012.
10. Alaimo A, Liñares GG, Bujjamer JM et al. Toxicity of blue led light and A2E is associated to mitochondrial dynamics impairment in ARPE-19 cells: implications for age-related macular degeneration. Arch Toxicol. 2019; 93(5): 1401-15. http://doi.org/10.1007/s00204-019-02409-6.
11. Ouyang X, Yang J, Hong Z et al. Mechanisms of blue light-induced eye hazard and protective measures: a review. Biomed Pharmacother. 2020; 130: 110577. http://doi.org/10.1016/j.biopha.2020.110577.
12. Brunk UT, Terman A. Lipofuscin: mechanisms of age-related accumulation and influence on cell function. Free Radic Biol Med. 2002; 33(5): 611-9. http://doi.org/10.1016/s0891-5849(02)00959-0.
13. Sparrow JR, Wu Y, Nagasaki T et al. Fundus autofluorescence and the bisretinoids of retina. Photochem Photobiol Sci. 2010; 9(11): 1480-9. http://doi.org/10.1039/c0pp00207k .
14. Cheng SN, Yang TC, Ho JD et al. Ocular toxicity of intravitreal indocyanine green. J Ocul Pharmacol Ther. 2005; 21(1): 85-93. http://doi.org/10.1089/jop.2005.21.85.
15. Querques G, Prascina F, Iaculli C et al. Retinal toxicity of indocyanine green. Int Ophthalmol. 2008; 28(2): 115-8. http://doi.org/10.1007/s10792-007-9112-3.
16. Landsman ML, Kwant G, Mook GA et al. Light-absorbing properties, stability, and spectral stabilization of indocyanine green. J Appl Physiol. 1976; 40(4): 575-83. http://doi.org/10.1152/jappl.1976.40.4.575.
17. Sato T, Karasawa Y, Ishikawa S et al. Potential Phototoxicity of Indocyanine Green in Retinal Pigment Epithelial Cells after Angiography under Ambient Illumination. Oxid Med Cell Longev. 2018; 2018: 6065285. http://doi.org/10.1155/2018/6065285.
18. Almeida FP, De Lucca AC, Scott IU et al. Accidental subretinal brilliant blue G migration during internal limiting membrane peeling surgery. JAMA Ophthalmol. 2015; 133(1): 85-8. http://doi.org/10.1001/jamaophthalmol.2014.3869.
19. Abdouh M, Chen Y, Goyeneche A et al. Blue Light-Induced Mitochondrial Oxidative Damage Underlay Retinal Pigment Epithelial Cell Apoptosis. Int J Mol Sci. 2024; 25(23): 12619. http://doi.org/10.3390/ijms252312619.
20. Soni A, Parameswarappa DC, Tyagi M et al. Brilliant Blue G toxicity in macular hole surgeries: A report on combined phototoxicity and dye-induced macular damage. Semin Ophthalmol. 2022; 37(1): 117-22. http://doi.org/10.1080/08820538.2021.1928717.
21. Bacsal KM, Chee SP. Trypan blue-associated retinal toxicity post complicated cataract surgery. Eye (Lond). 2006; 20(11): 1310-1. http://doi.org/10.1038/sj.eye.6702164.
22. Narayanan R, Kenney MC, Kamjoo S et al. Trypan blue: effect on retinal pigment epithelial and neurosensory retinal cells. Invest Ophthalmol Vis Sci. 2005; 46(1): 304-9. http://doi.org/10.1167/iovs.04-0703.
23. Pastor JC, Coco RM, Fernandez-Bueno I et al. Acute retinal damage after using a toxic perfluoro-octane for vitreo-retinal surgery. Retina. 2017; 37(6): 1140-51. http://doi.org/10.1097/IAE.0000000000001680.
24. Veritti D, Lanzetta P, Bandello F et al. Viscoelastic agent retention and failed macular hole surgery. Retin Cases Brief Rep. 2009; 3(1): 77-9. http://doi.org/10.1097/ICB.0b013e318158de4f .
25. Amigó A, Martinez-Sorribes P. Toxic Intraocular Syndrome. J Ophthalmic Vis Res. 2022; 17(1): 155-6. http://doi.org/10.18502/jovr.v17i1.10184.
26. Pichi F, Hay S, Abboud EB. Inner retinal toxicity due to silicone oil: a case series and review of the literature. Int Ophthalmol. 2020; 40(9): 2413-22. http://doi.org/10.1007/s10792-020-01418-0.
27. Kumoi M, Matsuda S, Matsumoto M et al. Toxic posterior segment syndrome caused by silicone oil tamponade resulting in postsurgical retinal vascular occlusion: a case report. Am J Ophthalmol Case Rep. 2025; 39: 102404. http://doi.org/10.1016/j.ajoc.2025.102404.
28. Muuss M, Karaivanova M, Skrzypczyk L et al. F4H5 Alleviates Increased Outflow Resistance Induced by Emulsified Silicone Oil In Vitro. Invest Ophthalmol Vis Sci. 2025; 66(11): 21. http://doi.org/10.1167/iovs.66.11.21.
29. Karakosta C, Downes SM. Progressive Retinal Toxicity Nine Years After Hydroxychloroquine Discontinuation: A Case Report. Cureus. 2025; 17(12): e98674. http://doi.org/10.7759/cureus.98674.
30. Eldeeb M, Chan EW, Omar A. Case Report: Hydroxychloroquine Retinopathy. Optom Vis Sci. 2018; 95(6): 545-9. http://doi.org/10.1097/OPX.0000000000001226.
31. Bertagnolio S, Tacconelli E, Camilli G et al. Case report: Retinopathy after malaria prophylaxis with chloroquine. Am J Trop Med Hyg. 2001; 65(5): 637-8. http://doi.org/10.4269/ajtmh.2001.65.637.
32. Souza Monteiro de Araújo D, Brito R, Pereira-Figueiredo D et al. Retinal Toxicity Induced by Chemical Agents. Int J Mol Sci. 2022; 23(15): 8182. http://doi.org/10.3390/ijms23158182.
33. Lin RC, Cantrill HL, Mieler WF. Retinal Toxicities Caused by Systemic Medications. Retinal Physician. 2007; November/December 2007.
34. Bonting SL, Caravaggio LL, Canady MR. Studies on sodium potassium-activated adenosine triphosphatase. X Occurrence in retinal rods and relation to rhodopsin Exp Eye Res. 1964; 3: 47-56.
35. McDonald HR, Schatz H, Allen AW et al. Retinal toxicity secondary to intraocular gentamicin injection. Ophthalmology. 1986; 93(7): 871-7. http://doi.org/10.1016/s0161-6420(86)33648-0.
36. Almeida LN, Canêdo MG, Almeida RN et al. Maculopatia isquêmica após injeção intravítrea de amicacina: relato de caso Macular infarction after intravitreal injection of amikacin: case report. Arq Bras Oftalmol. 2005; 68(6): 837-40. http://doi.org/10.1590/s0004-27492005000600023.
37. Doft BH, Barza M. Macular infarction after intravitreal amikacin. Br J Ophthalmol. 2004; 88(6): 850. http://doi.org/10.1136/bjo.2003.038885.
38. Hernández Pardines F, Tapia-Quijada H, Hueso-Abancens JR. A case of aminoglycosides induced retinal toxicity treated with megadoses of steroids and an intravitreal dexamethasone implant (Ozurdex(®)). Arch Soc Esp Oftalmol. 2016; 91(6): 288-91. http://doi.org/10.1016/j.oftal.2016.01.017.
39. Muid J, Awan MA. Haemorrhagic occlusive retinal vasculitis caused by intravitreal vancomycin. J Pak Med Assoc. 2020; 70(9): 1648-50. http://doi.org/10.5455/JPMA.46528.
40. Ksiazek S, Grover S, Mojica G et al. Indocyanine green toxicity of the retina after cataract surgery: a case report. Retin Cases Brief Rep. 2009; 3(2): 115-7. http://doi.org/10.1097/ICB.0b013e318162b123.
41. Yeh LK, Yang CS, Lee FL et al. Solar retinopathy: a case report. Zhonghua Yi Xue Za Zhi (Taipei). 1999; 62(12): 886-90.
42. McDonald HR, Harris MJ. Operating microscope-induced retinal phototoxicity during pars plana vitrectomy. Arch Ophthalmol. 1988; 106(4): 521-3. http://doi.org/10.1001/archopht.1988.01060130567038.
43. Witkin AJ, Chang DF, Jumper JM et al. Vancomycin-Associated Hemorrhagic Occlusive Retinal Vasculitis: Clinical Characteristics of 36 Eyes. Ophthalmology. 2017; 124(5): 583-595. http://doi.org/10.1016/j.ophtha.2016.11.042.
44. Hsu ST, Ponugoti A, Deaner JD et al. Update on Retinal Drug Toxicities. Curr Ophthalmol Rep. 2021; 9(4): 168-77. http://doi.org/10.1007/s40135-021-00277-x .
45. Hydroxychloroquine Toxicity. Weng CY, Kim JE, Leng T et al (eds.). EyeWiki, San Francisco 2025.
46. Wang G, Zhuo N, Liao Z et al. Retinal toxicity caused by hydroxychloroquine in patients with systemic lupus erythematosus: A case report. Medicine (Baltimore). 2021; 100(22): e25688. http://doi.org/10.1097/MD.0000000000025688.
47. Ding HJ, Denniston AK, Rao VK et al. Hydroxychloroquine-related retinal toxicity. Rheumatology (Oxford). 2016; 55(6): 957-67. http://doi.org/10.1093/rheumatology/kev357.
48. Pereira C D R, Miguel V S, Miguel TS et al. Early and progressive hydroxychloroquin retinal toxicity: 9-year follow-up with multimodal retinal imaging. Int J Med Ophthalmol. 2022; 4(2): 9-14. http://doi.org/10.33545/26638266.2022.v4.i2a.120.