EyeWorld Asia-Pacific September 2016 Issue

September 2016 10 EWAP FEATURE 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 presentation. Vision is 20/30 in the right eye (A) and no light perception in the left (B). Note the severe peripheral ischemia in the right eye (C) and complete non-perfusion in the left eye (D) on fluorescein angiography. Source: Ryan Terribilini Joint ASCRS/ASRS Task Force issues findings and recommendations regarding HORV by David F. Chang, MD, and Andre Witkin, MD T he first two cases of bilateral hemorrhagic occlusive retinal vasculitis (HORV) were published in 2014. 1 An additional four cases (3 bilateral and 1 unilateral) were reported in 2015. 2 All 11 of the reported eyes in those six cases had undergone otherwise uncomplicated cataract surgery with prophylactic intracameral vancomycin (1 mg/0.1 cc), and there was a delay of 1–14 days before the onset of the severe ischemic retinal vasculitis. The visual outcomes were poor. The authors postulated a delayed immune response to a surgical adjuvant, with vancomycin as the leading candidate. Because of the popularity of intracameral vancomycin for endophthalmitis prophylaxis, the American Society of Cataract & Refractive Surgery (ASCRS) and the American Society of Retina Specialists (ASRS) expeditiously formed a joint Task Force to further analyze the prevalence, potential etiology, treatment, and outcomes of this newly described complication associated with intraocular surgery. The Task Force includes ASRS members Steve Charles, MD , Dean Eliott, MD, J. Michael Jumper, MD, Andre J. Witkin, MD , and Charles C. Wykoff, MD , and ASCRS Cataract Clinical Committee members David F. Chang, MD , Richard S. Hoffman, MD , Nick Mamalis, MD , and Kevin M. Miller, MD . Drs. Charles, Jumper, and Miller also serve on the ASCRS Retina Clinical Committee. To better define the clinical characteristics of HORV, an online case registry was set up on the ASRS website for members to report new cases. Information about all surgical medications and adjuvants was requested with a particular goal of uncovering other associations in addition to (or besides) vancomycin. Retinal images including OCT, FA, and fundus photos were reviewed for each case by retina specialist members of the Task Force. In addition, to better understand the prevalence of this complication, an online “surveillance” survey was emailed to all ASCRS members soliciting any cases of suspected HORV. Positive respondents were sent additional queries for information that were followed up by Task Force retina specialists. Through these methods, a complete data set was compiled on 36 eyes of 22 patients with HORV. All of these eyes received intraocular vancomycin, either 1 mg/0.1 ml intracameral, 1 mg/0.1 intravitreal, or in the infusion bottle (10 mg into the balanced salt solution bottle). Despite intraocular anti-VEGF and steroid treatments, visual results were often very poor. Twenty-two of 36 eyes (61%) were 20/200 or worse, and 8 of 36 eyes (22%) were NLP. Neovascular glaucoma developed rapidly in 19 of 36 eyes (53%), often within 1–2 months. Seven of 36 eyes (19%) received an additional bolus of intravitreal vancomycin for treatment of presumed bacterial endophthalmitis. These patients had particularly poor outcomes; 5/7 of these eyes were NLP. There are currently 11 other cases of possible HORV for which we have not been able to collect a full data set or images, and all but two of these received intraocular vancomycin. We don’t think the latter two represent true HORV based on the information given to us so far. One case had poor vision starting on POD 1 and may represent medication toxicity with severe diffuse retinal microvascular occlusion with sparing of the larger retinal vessels. The second case looks more like a CRVO or combined CRAO/CRVO, with dilated and tortuous retinal veins and diffuse scattered small dot hemorrhages. The differential diagnosis of HORV includes acute postoperative endophthalmitis, viral retinitis, medication toxicity, and CRVO or combined CRAO/CRVO. In endophthalmitis, pain and severe continued on page 12