Eyeworld

EW NEWS & OPINION 22 September 2017 reconsider using vancomycin if you perform close sequential bilateral cataract surgery," Dr. Chang said. "It is important to realize that you may have HORV in the first eye in an ini- tially asymptomatic patient. Cases with a milder form of HORV in their first eye would only be diagnosable with a dilated fundus exam. "Based on the fact that HORV is extremely rare, we feel it is up to the surgeon's discretion to weigh the risk of HORV against the risk of endophthalmitis," Dr. Chang said. Intracameral moxifloxacin studies Dr. Chang said that he used rou- tine intracameral vancomycin for 18 years without any known cases of HORV. However, following the cases collected by the HORV Task Force, he switched to intracameral moxifloxacin based on studies that he collaborated on with the Aravind Eye Care System (AECS) in Tamil Nadu, India. 5,6 Approximately 60% of AECS cataract surgery is per- formed at little or no cost on charity patients using sutureless, manual small incision cataract surgery (MSICS). This technique involves a larger incision to manually remove an undivided nucleus, followed by implantation of a rigid PMMA IOL. Because of a historically higher rate of postoperative endophthalmitis with MSICS, routine IC moxifloxa- cin prophylaxis was started for all charity patients at one of AECS's 11 regional hospitals in August 2014. During a 14-month study period, comparison of 38,160 consecutive cases done immediately prior to this change with the first 37,777 consec- utive eyes that received IC moxiflox- acin showed a four-fold reduction in the rate of postoperative endoph- thalmitis rate with IC antibiotic prophylaxis. Following this study, AECS initiated routine IC moxifloxacin prophylaxis in all cataract patients at all 11 of its hospitals. An analysis of 617,453 consecutive cases during a 29-month period was published in June. There was a 3.5-fold reduction in the endophthalmitis rate in the 314,638 eyes that received IC moxi- floxacin, compared to the 302,815 eyes that did not. The reduction was three-fold among MSICS eyes and six-fold among phaco eyes. the prevalence, etiology, treatment, and outcomes of HORV associated with intraocular surgery. The Task Force, which is co-chaired by Dr. Chang, set up a registry available through both the ASCRS and ASRS websites and emailed a survey to all ASCRS members regarding potential cases of HORV in their practices. In addition to a comprehensive litera- ture search, the Task Force members conferred with immunologists and published its observations on 36 eyes in 23 patients diagnosed with HORV. 4 The Task Force found that all 36 eyes, 13 with bilateral and 10 with unilateral HORV, had exposure to vancomycin of different doses, routes of administration, manufac- turers, and with different adjuvants. All cases followed uncomplicated cataract surgery and were character- ized by delayed onset (range 1–26 days postoperatively; mean 8 days) of sudden, painless decreased vision. Visual acuity was commonly poor on presentation, but was also observed to be normal at first, in milder cases. HORV patients demonstrated sectoral intraretinal hemorrhage along the venules, peripheral retinal involvement with macular ischemia and whitening in advanced cases, sectoral retinal vasculitis, and retinal vascular occlusion on FA (corre- sponding to areas of hemorrhage). The visual results in these patients were generally very poor: 22 of 36 eyes (61%) had 20/200 or worse, and eight eyes (22%) had no light perception (NLP). Neovascular glaucoma was demonstrated in 20 eyes (56%), which was characterized by rapid onset and progression. Five of seven eyes that received addi- tional intravitreal vancomycin for presumed endophthalmitis resulted in NLP vision. In the 26 documented bilateral eyes (13 patients), the absence of immediate adverse events following surgery caused surgeons to proceed to second eye surgery, ultimately leading to bilateral HORV. Fellow eye reactions had a faster onset and more severe clinical course than in the first eye, consistent with type 3 hypersensitivity reactions. Unfor- tunately, no method exists to test for type 3 hypersensitivity reactions either pre- or post-HORV diagnosis. "We certainly think you should antibiotics, 84% were doing so with a direct intracameral (IC) injection, compared to 52% in 2007. Among the respondents using an intraocular antibiotic, 37% overall (and 52% of American respondents) were using vancomycin; moxifloxacin was used by 33% overall and cefuroxime by 26%. HORV Task Force outcomes Dr. Chang noted that this practice pattern has undoubtedly changed with subsequent reports linking hemorrhagic occlusive retinal vascu- litis (HORV) to intraocular vanco- mycin. 3 The HORV Task Force is a joint effort between ASCRS and the American Society of Retina Special- ists (ASRS), created on the heels of the first published retrospective case series of HORV in 11 eyes of six pa- tients, to advance understanding of Dr. Chang presented new information on intracameral antibiotics at the 2017 ASCRS•ASOA Symposium & Congress T he use of intraocular antibi- otic prophylaxis following cataract surgery has been increasing, according to a presentation given by ASCRS Cataract Clinical Committee member David F. Chang, MD, Los Altos, California, at the 2017 ASCRS•ASOA Symposium & Con- gress. According to two ASCRS member surveys conducted by the Cataract Clinical Committee, the percentage of surgeons using routine intraocular antibiotic prophylaxis increased from 30% in 2007 to 50% in 2014. 1,2 Of those using intraocular The latest on intracameral antibiotics Presentation spotlight Dr. Chang discusses intracameral antibiotics at the 2017 ASCRS•ASOA Symposium & Congress. Source: ASCRS

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