Eyeworld

EW CATARACT 44 June 2018 Pharmaceutical focus by Maxine Lipner EyeWorld Senior Contributing Writer all received vancomycin." This was either in the irrigating bottle, in- jected into the vitreous, or using an intracameral bolus of vancomycin, which was injected into the anterior chamber. Some patients were initially misdiagnosed as having endoph- thalmitis, Dr. Hoffman thinks. "The condition differs from endophthal- mitis in that the inflammation is much milder," he said, adding that there were likely patients who were initially presumed to have endoph- thalmitis and given intravitreal van- comycin as treatment. "Those eyes did the worst out of all of them," Dr. Hoffman said. "There were seven eyes that received additional treat- ment with vancomycin, and five of them went on to have no light perception vision." The HORV picture Dr. Mamalis described HORV as a severe hemorrhagic/occlusive vascu- litis. "Patients had significant visual loss," he said. "They had a tremen- dous amount of inflammation, and it was all associated with the vessels that were in the retina causing wide- spread hemorrhages and widespread disturbances of the vessels. It was causing an occlusive vasculitis, and we hadn't seen this before." Cases of HORV are typically diagnosed by the characteristics and by the temporal relationship to the cataract surgery. The delayed onset inflammation makes it unique. "Of- tentimes, when we see patients with inflammation after cataract surgery, in patients after relatively uncompli- cated cataract surgery," Dr. Mamalis said. As practitioners started seeing more of these cases, ASCRS in con- junction with the American Society of Retina Specialists (ASRS) put together a task force to look into the reports to determine why this was occurring. It started with around six case reports, said Richard Hoffman, MD, clinical associate professor of ophthalmology, Casey Eye Institute, Oregon Health Sciences University, Portland. "After further evaluation and polling, they discovered there were at least 36 eyes of 22 patients (with HORV)," Dr. Hoffman said. 1 With this condition, patients appeared fine on the first post- operative day. "There's a delayed onset of painless visual loss with a mild anterior chamber reaction and a mild-to-moderate vitreous inflammation," Dr. Hoffman said. "The patients have retinal hemor- rhage that is more pronounced in the peripheral retina with vascular occlusion." There was a predilection for the hemorrhages to be around the veins and to be peripheral, Dr. Hoffman continued, adding that in many patients there was a rapid progression of neovascularization of the iris and neovascular glaucoma. "I think the other interesting development with this condition is that we found a strong association with vancomycin," Dr. Hoffman said. "We weren't sure initially, but after we looked at the 36 eyes that met the criteria, we found that they It can occur even after routine cases, according to Nick Mamalis, MD, professor of ophthalmology, Moran Eye Center, University of Utah, Salt Lake City. "Initially physicians were seeing an extensive inflammatory vasculitis type of pattern that was occurring What to keep in mind H emorrhagic occlusive reti- nal vasculitis (HORV) is a devastating condition that has left many practitioners avoiding prophylactic use of vancomycin for cataract surgery. HORV concerns linger for many complicated cases. Dr. Chang's and others' research comparing Zepto to manual and femtosecond laser cap- sulotomy found it was consistently stronger in paired human cadaver eyes. 2 "It is with large, brunescent cataracts that we exert the most sur- gical force on the capsular bag and capsulorhexis," Dr. Chang said. "For example, with chopping we have to manually separate the two hemi-nu- clei much further apart to fracture the posterior nuclear plate." Pearls identified Surgeons have identified a variety of ways to improve the device's performance. "Initial experience has taught us the importance of retracting the push rod all the way back to its starting position before activating suction," Dr. Chang said. "Oth- erwise, insufficient suction could create a skip area in the cut, and this was a part of my learning curve." Among the pearls Dr. Yeu has found to improve efficiency with the device is extending wounds from the 2.2 mm required to 2.3 mm, which eases ingress and egress of the Zepto device. Dr. Waltz has found it unnec- essary to use capsular dye once a surgeon becomes comfortable with Zepto. "If you have a dense cataract and you are afraid of an anterior capsular rip, Zepto makes a precise 360 degree cut, so you release the pressure in a real way," Dr. Waltz said. "You can also put the Zepto be- hind a small pupil, and you can get a good 5.2 mm capsulotomy behind the pupil." EW References 1. Chang DF, et al. Precision pulse capsulot- omy: Preclinical safety and performance of a new capsulotomy technology. Ophthalmology. 2016;123:255–64. 2. Thompson VM, et al. Comparison of manual, femtosecond laser, and precision pulse capsulotomy edge tear strength in paired human cadaver eyes. Ophthalmology. 2016;123:265–74. Editors' note: Dr. Sretavan, Dr. Chang, and Dr. Waltz have financial interests with Mynosys. Dr. Yeu has no financial interests related to her comments. Contact information Chang: dceye@earthlink.net Sretavan: sretavan@mynosys.com Waltz: kwaltz56@gmail.com Yeu: eyeu@vec2020.com Reports continued from page 42 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 presenta- tion. Vision is 20/30 in the right eye (A) and no light perception in the left (B). There is severe peripheral ischemia in the right eye (C) and complete non-perfusion in the left eye (D) on fluorescein angiography. Source: Ryan Terribilini A B C D

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