Eyeworld

EW NEWS & OPINION 26 September 2016 Discussion on HORV association with intraocular vancomycin eyeCONNECTIONS excerpts Bilateral hemorrhagic occlusive retinal vasculitis in a 55-year-old man after cataract surgery with intracameral vancomycin 18 days (right eye) and 11 days (left eye) prior to presentation. Vision is 20/30 in the right eye (A) and no light perception in the left (B). Note the severe peripheral ischemia in the right eye (C) and complete non-perfusion in the left eye (D) on fluorescein angiography. Source: Ryan Terribilini continued on page 28 On July 20, the ASCRS and American Society of Retina Specialists (ASRS) Task Force on hemorrhagic occlusive retinal vasculitis (HORV) released their clinical alert to members of both societies. That same day, three members of the Task Force, ASRS representatives Andre Witkin, MD, and J. Michael Jumper, MD, along with former ASCRS president David F. Chang, MD, were signed into the eyeCONNECTIONS Cataract/Refractive listserv to answer members' questions "live." The following are excerpts of this discussion. Each discussant below gave the eyeCONNECTIONS Committee permission for their comments to be included in EyeWorld. Michelle Akler, MD, eyeCONNECTIONS Committee member Dr. Odette followed up with this question: "Are any of you perform- ing prophylactic intracameral or intravitreal injections of antibiotics for cataract or retina surgery at this time knowing the current informa- tion about possible HORV?" Dr. Chang answered: "(1) I was an early adopter of intracameral vancomycin 0.1 m at the end of sur- gery (1 mg) purely based on Howard compounded the vancomycin, and in two eyes the vancomycin was compounded at an outside facili- ty. There was no association with any one particular manufacturer of vancomycin; there were four different manufacturers in the seven cases in which the manufacturer was reported. This is why we think that it is a type III hypersensitivity to the drug rather than some adjuvant or diluent." S hannon Wong, MD, Austin, Texas, asked, "Have any of these HORV cases been associated with Tri- Moxi-Vanc [triamcinolone, moxifloxacin, vancomycin, Imprim- is Pharmaceuticals, San Diego]?" Andre Witkin, MD, Boston, responded, "As far as we know, none of the eyes in our series received combination triamcinolone and vancomycin. "Intravitreal Ozurdex [dexa- methasone, Allergan, Dublin] was used in three of 36 eyes once the HORV reaction was seen. Visual re- sults were HM, 20/40, and 20/60 in the three eyes, so it's possible there may have been some additional ben- eficial effect of intravitreal steroids in the patients with relatively good visual results. "Perhaps it's possible that the triamcinolone in combination tri- amcinolone-vancomycin may be at least partially protective against any immune reaction to the vancomy- cin. However, it's difficult to draw any definitive conclusions from such small numbers." John Odette, MD, Austin, Tex- as, asked Drs. Chang, Witkin, and Jumper, "Can you discuss in detail the formulation and types of vanco- mycin used for the 22 cases?" David Chang, MD, Los Altos, California, responded, "All 36 eyes received intraocular vancomycin, either 1 mg/0.1 ml intracameral (31/36 eyes), 2 mg/0.2 ml intracam- eral (2/36 eyes), 1 mg/0.1 intravitreal (1/36 eyes), or 10 mg inserted into the irrigation bottle (2/36 eyes). Operating room nurses prepared the antibiotics in the majority of cases in which formulation information was reported (18/24 eyes, or 75%). In four eyes, the hospital pharmacy A B C D

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