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17 EW NEWS & OPINION July 2016 by the ASCRS/ASRS HORV Task Force: David F. Chang, MD, Steve Charles, MD, Dean Eliott, MD, Richard S. Hoffman, MD, J. Michael Jumper, MD, Nick Mamalis, MD, Kevin M. Miller, MD, Andre J. Witkin, MD, and Charles C. Wykoff, MD • Surgeons desiring an alternative to vancomycin for intracameral pro- phylaxis may consider cefuroxime or moxifloxacin. 4 Recommendations for management of HORV • Consider avoiding intravitreal vancomycin if both bacterial endophthalmitis and HORV are in the differential. • Consider ocular and/or systemic work-up for other syndromes (e.g., viral retinitis). • Aggressive systemic and topical corticosteroids; consider peri- or intraocular steroids • Early anti-VEGF treatment • Early panretinal photocoagulation • If you identify a patient with HORV, please submit the clinical data to the HORV registry site (links from www.asrs.org and www.ascrs.org). Patient and surgeon names will be kept 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. This ASCRS/ASRS alert is provided for informational and educational purposes only. It is not intended to mandate or establish a specific standard of care or dictate the treatment of any particular patients. ASCRS and ASRS members must make independent judgments about the treatment of their patients based on all the facts and circumstanc- es relating to each patient's condition. Contact information Chang: dceye@earthlink.net Witkin: ajwitkin@gmail.com rare type III hypersensitivity reaction to vancomycin, rather than direct drug toxicity. This might be similar to leukocytoclastic vasculitis and He- noch-Schonlein purpura, which are type III hypersensitivity reactions in the skin that have also been rarely associated with vancomycin. Unfor- tunately, there is no current method to test for such hypersensitivity either pre- or post-HORV diagnosis. Fourteen of the 22 cases (64%) were bilateral. Because of the de- layed onset, HORV did not appear in the first eye until after surgery in the second eye in the 11 cases who un- derwent sequential bilateral cataract surgery (3 days to 3 weeks apart). In most of these 11 sequential bilateral cases, the first eye became symp- tomatic first, but bilateral HORV was diagnosed simultaneously during the initial examination. Even with a long delay between eyes in the re- maining 3 bilateral cases (9 months, 3 years, and 9 years) the second eye presented similarly to the first after the second eye underwent surgery. Use of intracameral antibiotic for endophthalmitis prophylaxis is increasing. In a 2014 ASCRS member survey, 50% of respondents were us- ing intracameral antibiotics. 3 Among those using intracameral antibiotic, vancomycin was used by 37% over- all and by 52% of American sur- geons. Many high volume practices using intracameral vancomycin have never knowingly experienced HORV, and the Task Force believes it to be extremely rare. Without knowing how many patients have received intracameral vancomycin, however, the actual rate is unknown. Considerations for intraocular vancomycin use • Because HORV appears to be ex- tremely rare, each surgeon should weigh the potential risk of HORV associated with vancomycin against the risk of endophthalmitis. • Reconsider using vancomycin with close sequential bilateral cataract surgery. • Surgeons using intraocular van- comycin with sequential cataract surgery should be aware that in addition to delayed onset, HORV may not cause symptoms in the first eye, and a dilated retinal examination may be the only way to detect it. postop day 1 • Delayed onset of sudden painless decreased vision (range 1–26 days postop; mean 8 days) • Visual acuity often poor on pre- sentation, but may be normal in mild cases • Mild to moderate anterior cham- ber and vitreous inflammation, with no hypopyon • Sectoral intraretinal hemorrhage in areas of non-perfusion (often along venules) • Peripheral retinal involvement in all cases, with macular ischemia and whitening in advanced disease • Sectoral retinal vasculitis and retinal vascular occlusion on FA, corresponding to areas of hemor- rhage • Rapid progression to neovascular glaucoma common (53%) Other associations • Intraocular vancomycin exposure during procedure • History of similar reaction in fellow eye • When both eyes involved, second eye often has faster onset and more severe course • Minimal to no corneal edema • Retinal hemorrhages are often large and/or confluent • Propensity for retinal venule involvement (although can affect both arteries and veins) • No significant increase in venous dilation or tortuosity • OCT: Hyper-reflectivity and thick- ening of the inner retinal layers; CME not a key feature • Therapy with intravitreal vanco- mycin for presumed endophthal- mitis associated with poor out- comes HORV is different from ischemic CRVO, which is unilateral, usual- ly presents on postop day 1 when associated with cataract surgery, and is associated with diffuse small intraretinal hemorrhages; converse- ly, HORV is often bilateral, has a delayed onset, and often presents with large patches of intraretinal hemorrhage only in sectors of retinal vascular occlusion. CME and severe vascular dilation and tortu- osity are key features with CRVO, but not HORV, and the rates of NLP vision and of neovascular glaucoma are higher with HORV. Consulted immunology experts hypothesize this might represent a F ollowing the first published series of hemorrhagic occlusive retinal vasculi- tis (HORV), 1,2 the Ameri- can Society of Cataract & Refractive Surgery (ASCRS) and the American Society of Retina Special- ists (ASRS) formed a joint Task Force to further analyze the prevalence, potential etiology, treatment, and outcomes of this complication associated with intraocular surgery. An HORV case registry was devel- oped and made accessible through the ASRS website, www.asrs.org, and an online surveillance survey was emailed to all ASCRS members. In addition to the first 6 cases reported, 1,2 we have identified at least 16 additional cases of HORV for a total of 22 cases. Fourteen cases were bilateral and 8 were unilater- al, for a total of 36 eyes. Twelve of the cases occurred in 2015–2016, 5 cases occurred in 2013–2014, and the other 5 cases were prior to 2013. The age range was 51–84 (mean 68 years). Although reporting and data collection are ongoing, preliminary findings from these 22 cases warrant this special Clinical Alert because of their potential impact on patient safety. HORV appears to be extremely rare, and can occur following any in- traocular procedure (usually cataract surgery). Presentation is delayed, with a mean onset of symptoms 8 days after the procedure. Although the cause of HORV is currently unproven, there is a strong asso- ciation with the use of intraocular vancomycin (including intravitreal, intracameral bolus, and irrigating solution containing vancomycin). All 36 eyes from these 22 cases received intraocular vancomycin. As of now, there has not been an association with one formulation or one manufacturer. Visual outcomes were often poor; 22/36 eyes (61%) were 20/200 or worse, and 8/36 eyes (22%) were NLP. Notably, 7 of 36 eyes (19%) received an additional bolus of intra- vitreal vancomycin for treatment of presumed bacterial endophthalmitis. These patients had particularly poor outcomes, and 5/7 eyes were NLP at most recent follow-up. HORV characteristic findings • Occurs after intraocular procedure with normal undilated exam on Clinical Alert: HORV association with intraocular vancomycin

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