Eyeworld

EW NEWS & OPINION 16 July 2016 hypersensitivity reactions start in the venous system, which would be consistent with the appearance of HORV, which appears to affect reti- nal venules more than the arterioles. Based on the cases collected to date, the Task Force Clinical Alert outlined the clinical pattern and findings with HORV. Recommen- dations for treatment and manage- ment were given. Without know- ing the number of eyes that have received vancomycin, and without routine dilated retinal examination following uncomplicated cataract surgery, it is impossible to deter- mine the prevalence of HORV. Our 2014 ASCRS member survey found that 50% of respondents were using intracameral antibiotics. 3 Among those using an intracameral anti- biotic, vancomycin was used by 37% overall and 52% of American surgeons. We therefore think that severe HORV is extremely rare. However, some cases of HORV may also be missed or misdiagnosed— particularly if there are milder cases causing peripheral vasculitis that do not affect vision. Such milder cases of HORV would have only been discovered with a dilated postoper- ative fundus examination. It is also possible that prior cases of presumed endophthalmitis (cases without hypopyon and retinal findings that were out of proportion to anterior chamber and vitreous inflammation) were actually cases of HORV. Since the 2015 HORV paper was pub- lished, a number of retina specialists have come forward with cases that were previously undiagnosed but now seem to represent HORV. Now that a registry has been established and with greater awareness of the syndrome, we hope to gain a better understanding of the frequency of HORV moving forward. Because HORV is probably rare, the Task Force is not recommending that surgeons discontinue using intraocular vancomycin prophylaxis at this time. Although the ASCRS survey reflects that there is no con- sensus on the necessity of intracam- eral antibiotic prophylaxis or which agent is best, the popularity of intraocular vancomycin prophylaxis is likely based on several factors, in- cluding safety, availability, coverage, and efficacy against drug resistant pathogens. 4 Surgeons should con- tinue to weigh the relative merits of prophylactic intraocular vancomy- cin use in preventing endophthalmi- tis, with the additional knowledge that intraocular vancomycin is likely associated with HORV, a distinctly rare and potentially devastating disease. In addition, surgeons using vancomycin prophylaxis with sequential cataract surgery should be aware that in addition to delayed onset of 1–3 weeks, HORV may be asymptomatic in the first eye and a dilated fundus exam may be the only way to detect it. Although there is no FDA approved commercial an- tibiotic formulation for intracameral use, compounding pharmacies can formulate intracameral cefuroxime and moxifloxacin if an alternative is desired. The ASCRS Cataract Clinical Committee published a white paper reviewing the different antibiotic options for intracameral prophylaxis in 2014. 4 If you experience or become aware of a case of HORV, please be sure that it is reported on the HORV registry, which can be ac- cessed through links at www.asrs. org and www.ascrs.org. The identity of the patient and attending oph- thalmologists will be kept strictly confidential. EW References 1. Nicholson LB, Kim BT, Jardon J, et al. Severe bilateral ischemic retinal vasculitis following cataract surgery. Ophthalmic Surg Lasers Imaging Retina. 2014;45:338–342. 2. Witkin AJ, Shah AR, Engstrom RE, Kron-Gray MM, et al. Postoperative hemorrhagic occlu- sive retinal vasculitis: Expanding the clinical spectrum and possible association with vancomycin. Ophthalmology. 2015;122: 1438-1451. 3. Chang DF, Braga-Mele R, Henderson BA, Mamalis N, et al. Antibiotic prophylaxis of postoperative endophthalmitis after cata- ract surgery: Results of the 2014 ASCRS member survey. J Cataract Refract Surg. 2015;41:1300–1305. 4. Braga-Mele R, Chang DF, Henderson BA, Mamalis N, et al. Intracameral antibiotics: Safety, efficacy, and preparation. J Cataract Refract Surg. 2014;40:2134–2142. Contact information Chang: dceye@earthlink.net Witkin: ajwitkin@gmail.com Joint ASCRS/ASRS continued from page 8 A 68-year-old woman presented with decreased vision 10 days after otherwise uncomplicated unilateral cataract surgery; intracameral vancomycin (1 mg/0.1 ml) was used at the end of the case. Despite treatment with systemic corticosteroids, valacyclovir, PRP, and anti-VEGF injections, visual outcome was counting fingers at 1 foot. Image A: Widefield color photograph demonstrates diffuse peripheral retinal vascular occlusion and associated large patches of retinal hemorrhage following the retinal venules. Ischemic macular whitening is evident. The retinal veins are not tortuous or dilated. Image B: Widefield FA demonstrates retinal vascular occlusion in areas of retinal hemorrhage. Staining of retinal venules is evident. Source: Rahul Mandiga, MD A B

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