Eyeworld

123 EW FEATURE April 2017 • Controversies in cataract surgery lial growth factor treatments and panretinal laser photocoagulation treatment are recommended as well. were 20/200 or worse, and 22% (8/36) had no light perception. "We have yet to identify a single case of confirmed HORV that did not receive vancomycin. In addi- tion, there were multiple sources of vancomycin used in these cases, which suggests that it is the drug rather than an adjuvant associated with a particular manufacturer or batch," Dr. Chang said. Immunologists consulted by the ASCRS/ASRS task force said the delayed response after vancomycin administration is consistent with a Type III hypersensitivity reaction. "This is a delayed hypersensi- tivity reaction in which antigen-an- tibody immune complexes are deposited into tissues such as vas- cular walls where they incite severe inflammation through activation of the complement cascade. Type III reactions often preferentially involve the venules and would be more se- vere upon repeat antigen exposure," Dr. Chang said. Intravenous vancomycin has previously been implicated as causing Type III hypersensitivity reactions, such as leukocytoclastic vasculitis. 4–6 Treatment Dr. Miller said physicians first need to rule out other conditions that could look like HORV, such as viral retinitis, endophthalmitis, or CRVO. While it's too late to reverse the damage that has already occurred, treatment upon diagnosis of HORV is all about downstream damage control, he said. "We're talking about using high- dose systemic and topical corticoste- roids," Dr. Mamalis said. "We want to do everything we can to decrease the inflammatory response and to limit it. People may even want to consider intravitreal corticosteroids because that's where you get a high dose of corticosteroids into the eye where this reaction is occurring." In fact, three eyes in the most recently published study received intravitreal dexamethasone implants upon presentation with HORV and ended up seeing 20/40, 20/70, and hand movements, respectively. "It's possible that the intravit- real steroids may be targeting the inflammation in the eye, specifical- ly," Dr. Witkin explained. Because patients with HORV often go on to develop neovascular glaucoma, due to the severity of ischemia in the retina, early inter- vention with anti-vascular endothe- Prevention Antibiotic prophylaxis became more widespread after the European Society of Cataract and Refractive continued on page 124

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