Eyeworld

EW NEWS & OPINION October 2017 23 Dr. Stiverson then discussed the historic role of vancomycin. He began using it in Colorado in 2002, and an ASCRS survey at that time indicated that other high volume cataract surgeons were also using it. The virtues of vancomycin are well known, he said. Vancomycin is the antibiotic of choice for almost all endophthalmitis cases, he said, but the biggest concern is hemorrhagic occlusive retinal vasculitis (HORV). "From 2002–2005, we put van- comycin in the balanced salt solu- tion bottle but reformed the anterior chamber and hydrated the incision with plain balanced salt solution," Dr. Stiverson said. "We did 12,000 surgeries and had five cases of en- dophthalmitis." From 2005–2016, reformation of the anterior chamber and stromal hydration of the inci- sion were done with balanced salt solution containing vancomycin, and Dr. Stiverson said there were 55,000 cases without incidence of endophthalmitis. Dr. Chang discussed the rare but devastating complication of HORV, which he said is one of the worst complications that can happen during cataract surgery because of the potential for bilateral blindness. This was first brought to surgeons' attention in 2015 with a paper published in Ophthalmology. The rec- ommendation was made to consider avoiding intracameral vancomycin use for routine prophylaxis. "Given the widespread use of vancomycin, many of us were concerned about drawing this conclusion from a series of just six patients," Dr. Chang said. ASCRS and the American Society of Retina Specialists (ASRS) formed an HORV Task Force to analyze the prevalence, etiology, treatment, and outcomes of this disease. They set up an online registry, conducted an e-survey of the ASCRS membership, did a literature search, and consult- ed with immunologists. The paper detailing these results was published in Ophthalmology in May, Dr. Chang said. It reported a series of HORV in 36 eyes of 23 patients (13 bilat- eral and 10 unilateral), all of which received intraocular vancomycin. It could occur 1–21 days after surgery, he said, adding that if the second eye received vancomycin, the onset of HORV was often faster and more severe. Dr. Chang offered recommen- dations for management. He said to consider avoiding intravitreal vanco- mycin if HORV is suspected, consid- er an ocular and/or systemic work- up for other syndromes if there is an unclear diagnosis, use aggressive systemic and topical corticosteroids, consider intraocular steroids, use early anti-VEGF treatment, and use early pan-retinal photocoagulation. Dr. Chang said that HORV is most likely a type III delayed hyper- sensitivity to vancomycin. Because there is no specific test for type III hypersensitivity, it is difficult to prove, but every confirmed case of HORV to date received intraocular vancomycin following uncompli- cated cataract surgery. In addition, systemic vancomycin causes a sim- ilar type III hypersensitivity called leukocytoclastic vasculitis with delayed onset and a predilection for venules. A 2014 ASCRS member sur- vey found that 50% of respondents were using intracameral antibiotic, with vancomycin being the most common agent (37% overall and 52% of American respondents). The HORV Task Force offered several considerations, Dr. Chang said. These include weighing the risk of HORV against the risk of endoph- thalmitis when using vancomycin, reconsidering vancomycin with close sequential bilateral cataract surgery, and knowing that HORV may not cause symptoms in the first eye and a dilated retinal exam may be the only way to detect it. He said that many surgeons have switched to using intracameral cefuroxime or moxifloxacin in light of the poten- tial for HORV. View the full presentation of this webinar at www.ascrs.org/cen- ter-for-learning/video/antibiotic-pro- phylaxis-cataract-surgery. EW Editors' note: Dr. Mah has financial in- terests with Alcon (Fort Worth, Texas), Allergan (Dublin, Ireland), and Bausch + Lomb (Bridgewater, New Jersey). Drs. Chang, Shorstein, and Stiverson have no financial interests related to their comments. Contact information Chang: dceye@earthlink.net Mah: Mah.Francis@scrippshealth.org Shorstein: NShorstein@eyeonsight.org Stiverson: rk.53stiverson@gmail.com Uniform epithelium removal in 5 - 7 seconds Corneal Xlinking, PRK Advanced Surface Ablation Improved clinical outcomes of CXL and PRK with Amoils Epithelial Scrubber Visit us at AAO 2017 in booth # 553 Minimize total procedure time Avoid alcohol damage to surrounding tissue No need for subsequent scraping T. 800.461.1200 www.innovativexcimer.com order online www.innovativexcimer.com AMOILS EPITHELIAL SCRUBBER AMOILS www.innovativexcimer.com

• Blank Page
• Blank Page (1)