Eyeworld

EW NEWS & OPINION 28 September 2016 what I now consider the single worst complication of cataract surgery— bilateral severe HORV." J. Michael Jumper, MD, San Francisco, commented, "I do still use intravitreal vancomycin as treatment for bacterial endophthal- mitis. To me, the risk/benefit ratio for using intraocular vancomycin as prophylaxis is very different than using it as treatment. If you look at the number of HORV cases that we have gathered and the time period they encompass, this is a very rare event. The problem is that it is a devastating event when it occurs. The fact that this reaction can be delayed beyond the common time interval for sequential bilateral cat- aract surgery gives risk for bilateral blindness, often in someone with excellent vision potential prior to cataract surgery." William Myers, MD, Chicago, posed the question, "Are any of you or your allergy consultants aware of any evidence that steroids given at any time reduce the risk of type III reactions?" Dr. Witkin responded, "As with other hypersensitivity reactions, treatment for type III hypersensi- tivity is largely supportive, and the mainstay of supportive treatment is corticosteroid medications. In HORV, it is likely that steroids are most important in the acute phase and play less of a role in long-term treatment, as the drug clears quickly and shouldn't continue to incite an ongoing reaction. Sensitization may occur in some hypersensitivity reac- tions, but doesn't necessarily occur in others. At this time, it is unclear if sensitization occurs in HORV, but there were several cases in which the reaction was worse in the second eye, suggesting that some patients may be sensitized to the drug. Oth- ers have worse disease in the first eye, or equal disease, suggesting that perhaps they may have already been sensitized or are not undergoing as much of a sensitization reaction." Jeffery Liegner, MD, Sparta Township, New Jersey, said, "I was one of the [early readers] of the ASCRS policy statement. It is a balanced, cautionary statement that merits our universal consideration. The Task Force led by Dr. Chang should be commended. "I have suggested that all HORV patients receive intradermal skin testing with vancomycin to confirm the vancomycin immune (type III) reaction. … I currently understand that none have had this testing; this should be done on every individ- ual who gave his or her precious "(4) Because of my strong fondness for vancomycin, I was per- sonally hoping that we would find less incriminating evidence. The Task Force started out with an open mind, unconvinced that vancomy- cin was the cause. We looked hard for other potential drugs, adjuvants, and interactions. We did an ASCRS surveillance survey to our member- ship and followed up with every person who reported a possible HORV—both with and without van- comycin. In the end, we didn't find a convincing HORV case that was not associated with vancomycin. "(5) Just because I personally switched, I would not go so far as to say no one should be using intra- cameral vancomycin. In drafting the alert, we tried to walk that fine line of informing surgeons with- out painting everyone into a risk management corner. In my personal view, intracameral antibiotics, and certainly intracameral vancomy- cin, have prevented many cases of endophthalmitis over a long period of time. The risk of HORV appears to be very small fortunately, with many like myself having never ex- perienced this complication despite many tens of thousands of cases. So each surgeon must make his or her own decision, and I do not think us- ing vancomycin is 'contraindicated.' I perform so many bilateral surger- ies spaced 1 to 2 weeks apart, and I don't want to press my luck with "(2) Based on what I learned on our Task Force, I stopped using vancomycin earlier this year and switched to intracameral moxiflox- acin. The other surgeons at our ASC have since followed suit. "(3) We now use compounded moxifloxacin from Leiters Com- pounding Pharmacy (1 mg/0.1 ml), which has a very stable shelf life and is less expensive than a bottle of Vigamox [moxifloxacin, Alcon, Fort Worth, Texas]. In addition, you cannot sterilize a bottle of Vigamox, and it isn't manufactured with the intent of intracameral injection. Gimbel's experience that he person- ally shared with me. That was more than 15 years ago. I've used this routinely ever since for every case in my high volume practice and am not aware of ever having had any complication from it. My personal anecdotal belief is that it has saved me from having endophthalmitis cases that would be proportionate to my volume. Every surgeon at our eye-only ASC adopted intracameral vancomycin eventually, and we saw a drop in our overall infection rate at the ASC. Discussion continued from page 26 " I'm not sure there is a universal right or wrong answer. Best judgment requires data and informed analysis. " –Jeffery Liegner, MD eyeCONNECTIONS is an online discussion forum that allows members to communicate directly with peers. ASCRS members are able to collaboratively view, comment, and share ophthalmic informa- tion with others. Topic-specific discussion lists are available for cataract/refractive, glaucoma, business, comprehensive, and young physicians. About eyeCONNECTIONS ASCRS members can access eyeCONNECTIONS at eyeconnections.org.

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