Eyeworld

EW NEWS & OPINION 18 July 2016 by Liz Hillman EyeWorld Staff Writer the opinion this will ultimately be shown to be vancomycin-induced HORV." Neal Shorstein, MD, Kaiser Permanente, Walnut Creek, California Intracameral cefuroxime was the first line endophthalmitis prophy- laxis for Dr. Shorstein's group nearly a decade ago based on findings from the multicenter, randomized control trial by the European Society of Cat- aract & Refractive Surgeons. 3 But 15% of their patients were allergic to penicillin or cephalo- sporin, making them suboptimal candidates for cefuroxime. In these patients, Dr. Shorstein said they started using moxifloxacin. Even Dr. Shorstein said he thinks there may still be a place for intra- cameral vancomycin—such as in patients who have a history of infec- tion or colonization with MRSA— and thus, he encourages more research to better understand the mechanism behind the conditions that could be causing HORV. Overall, Dr. Shorstein said his bottom line is that injecting an in- tracameral antibiotic of some kind is more favorable than not. "Presently, I think patients incur a much higher risk of endophthalmitis if physicians don't inject any intracameral anti- biotic than of getting HORV if they inject intracameral vancomycin." Experts weigh in on recommendations regarding rare but "strong association" between HORV cases and intracameral vancomycin F ollowing the first published data showing a possible association with intraoc- ular vancomycin use and postoperative hemorrhagic occlusive retinal vasculitis (HORV), 1,2 ASCRS and the American Society of Retina Specialists (ASRS) formed a joint Task Force to investigate, make recommendations, and establish an HORV registry to collect more information. In its Clinical Alert (see page 17 of this issue of EyeWorld), the Task Force states that while the "cause of HORV is currently unproven, there is a strong association with the use of intraocular vancomycin." There are still many unknowns regarding intraocular vancomycin and rare cases of HORV. Coupled with the proven benefits of using the antibiotic to reduce risk of endophthalmitis, there are various opinions on both. EyeWorld spoke with a few physicians about the Clinical Alert and their own takes on the topic. Opinions on intracameral antibiotics and ASCRS/ASRS alert then though, 1% of patients were allergic to both classes of drugs. These patients received intracameral vancomycin. "We knew we wanted to give an intracameral antibiotic to 100% of patients so we started with cefu- roxime because that had the best evidence. That has always been our default drug; we haven't changed from that. Moxi was the second line and vanco was the third line," Dr. Shorstein said. In light of the recent informa- tion regarding rare cases of HORV and intracameral vancomycin, Dr. Shorstein said, based on the annu- al volume of cataract surgeries in Kaiser Permanente's Northern Cal- ifornia system, which is more than 38,000 a year, "we had to weigh the risks and benefits." "In a recent study, we found that the organisms that cause en- dophthalmitis in our system were most sensitive to vancomycin. On the other hand, whereas a single ophthalmologist practicing in the United States may never experience HORV if he or she continues to use vancomycin, the chances of a large group like ours finally encountering a case of HORV is higher because of our annual volume of cataract surgery," he said. As such, Dr. Shorstein said Kaiser Permanente's cataract sur- gery research group, much like the ASCRS/ASRS Task Force's recommen- dation, is advising, although not mandating, its ophthalmologists avoid vancomycin on immediately sequential bilateral cataract surgery (ISBCS) patients. For delayed sequen- tial bilateral cataract surgery, he said the recommendation is to wait at least 4 weeks. Dr. Shorstein said his local group will continue to use cefurox- ime as a first line antibiotic prophy- laxis and moxifloxacin as a second line if there is an allergy to the first. If in the rare case there is an allergy associated with both, Dr. Shorstein said physicians have 3 choices: not inject an intracameral antibiotic at all (which he does not suggest); inject vancomycin knowing there is a very small risk of HORV; or ask the patient more about his or her allergic reaction to penicillin, and without a history of anaphylaxis, ad- minister cefuroxime since the risk of cross-reactivity is extremely remote. 4 Richard Kent Stiverson, MD, Kaiser Permanente, Denver Dr. Stiverson said he has used vanco- mycin since 2006, including in more than 1,750 patients who have had ISBCS since 2013. "The data supporting intracam- eral antibiotics is impressive in my opinion," Dr. Stiverson said. Yet in light of recent data re- garding vancomycin and HORV, Dr. Stiverson said he will be changing his habits somewhat. "At first, I thought we would be in the clear as we use vancomy- cin at a lower dose in the irrigation solution, but that is not the case as HORV has been reported with this method as well," he said. As such, Dr. Stiverson said he will continue using vancomycin for unilateral cataract surgery cases with 6 weeks between surgeries. For ISBCS or patients who wish to have unilat- eral surgery within the 6-week time frame, he will use moxifloxacin. "I think the [ASCRS/ASRS] alert is informative, restrained, and as evidence-based as it can be at this time," Dr. Stiverson said, adding that there is still very much that is not known about the relationship between HORV and intracameral vancomycin, but "what we do know is profoundly disturbing. I am of Jeffrey Liegner, MD, Eye Care Northwest, Sparta Township, New Jersey Dr. Liegner said he has used intraca- meral and intravitreal vancomycin in every case he's had for the last 3 years, adding it to his practice after perceiving an increased risk of MRSA in his community. He routinely combines vancomycin with moxi- floxacin and triamcinolone, a me- dium strength steroid that remains active inside the eye for 3 weeks postoperatively. "The risk of something ver- sus the benefits of something are carefully weighed by the judicious surgeon, and decisions are made that sometimes embrace risk in exchange for benefit," he said. "In this situation, vancomycin provides protection against MRSA that is not duplicated by moxifloxacin or [cefuroxime]." Bringing the possible associa- tion between intracameral vancomy- cin use and HORV into the equation caused Dr. Liegner to weigh the risk of HORV compared to the benefit of MRSA prophylaxis. Calling the ASCRS/ASRS Clinical Alert a well-structured and well-for- mulated document, Dr. Liegner said he is not going to alter his use of vancomycin based on the current knowledge. As of right now, Dr. Liegner said he thinks far more MRSA cases can be prevented with vancomycin use compared to HORV cases that could be prevented with- out its use. "I think there is a sense of worry out there. As with any profession, there are some individuals who are more inclined to do risk analysis and take risk, and there are others who are profoundly conservative and avoid risk wherever it might be, even if it is in exchange for a differ- ent kind of adverse event," he said.

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