Eyeworld

EW FEATURE 124 5. Pongruangporn M, et al. Vancomycin-asso- ciated leukocytoclastic vasculitis. Case Rep Infect Dis. 2011:356370. 6. Davey PL, et al. Antibiotic hypersensitivity reactions and approaches to desensitization. Clin Infect Dis. 2013;58:1140–8. 7. Endophthalmitis Study Group European Society of Cataract and Refractive Surgery, Refractive S. Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors. J Cataract Refract Surg. 2007;33:978–8. 8. Chang DF, et al. Antibiotic prophylaxis of postoperative endophthalmitis after cat- aract surgery: results of the 2014 ASCRS member survey. J Cataract Refract Surg. 2015;41:1300–5. 9. Rhee, DJ, et al. Report for antibiotic eyedrop regimen for cataract surgical patients survey. 2016. ASCRS Clinical Committee Report. 2016. Editors' note: The physicians inter- viewed for this article have no financial interests related to their comments. Contact information Chang: dceye@earthlink.net Mamalis: nick.mamalis@hsc.utah.edu Miller: kmiller@ucla.edu Witkin: AWitkin@tuftsmedicalcenter.org contemplating using vancomycin, they should probably be separating their surgery by 4 weeks or more, and making sure the patient is asymptomatic in the first eye before they move onto the second eye," Dr. Miller said. What's next Michael Teske, MD, The Eye Insti- tute, Salt Lake City, at the 2017 Eye- World Surgical Summit in Park City, Utah, noted several unanswered questions regarding vancomycin-as- sociated HORV. • Do some people clear vancomy- cin (and other drugs) at different rates from the eye, leading to drug toxicity? • Are there other factors that could be preventing drug clearance in a minority of patients (e.g., postop IOP spike, hypotony, retained viscoelastic)? • Are there milder forms of disease that are going unnoticed, since most patients aren't dilated until later in the postop course? Dr. Witkin pointed out that as of right now, clinicians don't defin- itively know whether vancomycin is actually the cause of the disease. At this point, there is also not a test to determine who may and who may not be at risk for this type of reaction. There is no skin test to predict or confirm a Type III hypersensitiv- ity in known HORV patients, Dr. Chang said. "Clearly [vancomycin] is a use- ful agent. It's been used by so many people for so many years, and it kills important bugs," Dr. Miller said. "It would certainly be nice if we could select individuals who are going to have a problem and not treat them with it, but have it available to treat other patients. But we don't have any way of doing that currently. There is probably going to be some genetic susceptibility. If we can iden- tify those genetic factors, that could be an area of future research." Going forward, Dr. Chang reminded his colleagues of the permanent online registry accessi- ble through the ASCRS and ASRS websites at www.ascrs.org and www. asrs.org. "We urge ophthalmologists to report suspected cases so that we can continue to learn about the frequen- cy and characteristics of this sober- ing complication," he said. EW References 1. Witkin AJ, et al. Vancomycin-associated hemorrhagic occlusive retinal vasculitis. Ophthalmology. 2016. Article in ress. 2. Nicholson LB, et al. Severe bilateral ischemic retinal vasculitis following cataract surgery. Ophthalmic Surg Lasers Imaging Retina. 2014;45(4):338–42. 3. Witkin AJ, et al. Postoperative hemorrhag- ic occlusive retinal vasculitis: Expanding the clinical spectrum and possible asso- ciation with vancomycin. Ophthalmology. 2015;122(7):1438–51. 4. Heijnen EB, et al. Purpura in a patient re- ceiving vancomycin: a leukoclastic vasculitis? J Cardiothorac Vasc Anesth. 2011;25:390–1. Surgeons published a 2007 paper that found a reduced rate of post- operative endophthalmitis with use of intracameral cefuroxime. 7 A 2014 ASCRS survey confirmed increas- ing use of intracameral antibiotics among membership, usually in con- junction with topical perioperative antibiotics. 8 At that time, vancomy- cin was used by 37% of the respon- dents who administered intraocular antibiotics. According to a survey of 556 domestic ASCRS members con- ducted in 2016 ahead of the ASCRS/ ASRS HORV clinical alert, 22.1% of all survey respondents used vanco- mycin during cataract surgery. 9 Without a commercially avail- able, U.S. Food and Drug Adminis- tration-approved antibiotic formu- lation for use in the eye, Dr. Witkin said vancomycin is among the easiest to formulate. "People have a lot of comfort with it; it has a very broad coverage of gram-positive microorganisms and had previously been used in ophthalmology for many years with- out any reported issues," he said. But with even a small risk for HORV, should vancomycin be used intracamerally? Recommendations put forth by the ASCRS/ASRS clinical alert in- clude each surgeon "[weighing] the potential risk of HORV associated with vancomycin against the risk of endophthalmitis." If a physician determines the risk for endophthalmitis without an intracameral antibiotic is more than the risk of TASS or HORV with one, Dr. Miller said a preventative measure could involve the surgical schedule. "One thing surgeons should consider if they're going to use van- comycin and they're staging these things close together—some of these things don't show up until 3 weeks after surgery … for anybody that's Controversies in cataract surgery • April 2017 Vancomycin-associated continued from page 123 " We urge ophthalmologists to report suspected cases so that we can continue to learn about the frequency and characteristics of this sobering complication " —David Chang, MD Considerations for intraocular vancomycin use • Because HORV appears to be extremely 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 vancomycin 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. • Surgeons desiring an alternative to vancomycin for intracameral prophylaxis may consider cefuroxime or moxifloxacin. 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 intra-ocular 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 or www.ascrs.org) Patient and surgeon names will be kept confidential. Source: ASCRS/ASRS clinical alert

• Blank Page
• Blank Page (1)