EyeWorld Asia-Pacific September 2016 Issue

September 2016 18 EWAP FEATURE Opinions on intracameral antibiotics and ASCRS/ASRS alert by Liz Hillman EyeWorld Staff Writer Experts weigh in on recommendations regarding rare but “strong association” between HORV cases and intracameral vancomycin F ollowing the first published data showing a possible association with intraocular vancomycin use and postoperative hemorrhagic occlusive retinal vasculitis (HORV), 1,2 ASCRS and the American Society of Retina Specialists (ASRS) formed a joint Task Force to investigate, make recommendations, and establish an HORV registry to collect more information. In its Clinical Alert (see page 15 of this issue of EyeWorld Asia- Pacific ), the Task Force states that while the “cause of HORV is currently unproven, there is a strong association with the use of intraocular vancomycin.” There are still many unknowns regarding intraocular vancomycin and rare cases of HORV. Coupled with the proven benefits of using the antibiotic to reduce risk of endophthalmitis, there are various opinions on both. EyeWorld spoke with a few physicians about the Clinical Alert and their own takes on the topic. Neal Shorstein, MD, Kaiser Permanente, Walnut Creek, California Intracameral cefuroxime was the first line endophthalmitis prophylaxis for Dr. Shorstein’s group nearly a decade ago based on findings from the multicenter, randomized control trial by the European Society of Cataract & Refractive Surgeons. 3 But 15% of their patients were allergic to penicillin or cephalosporin, making them suboptimal candidates for cefuroxime. In these patients, Dr. Shorstein said they started using moxifloxacin. Even then though, 1% of patients were allergic to both classes of drugs. These patients received intracameral vancomycin. “We knew we wanted to give an intracameral antibiotic to 100% of patients so we started with cefuroxime because that had the best evidence. That has always been our default drug; we haven’t changed from that. Moxi was the second line and vanco was the third line,” Dr. Shorstein said. In light of the recent information regarding rare cases of HORV and intracameral vancomycin, Dr. Shorstein said, based on the annual volume of cataract surgeries in Kaiser Permanente’s Northern California system, which is more than 38,000 a year, “we had to weigh the risks and benefits.” “In a recent study, we found that the organisms that cause endophthalmitis in our system were most sensitive to vancomycin. On the other hand, whereas a single ophthalmologist practicing in the United States may never experience HORV if he or she continues to use vancomycin, the chances of a large group like ours finally encountering a case of HORV is higher because of our annual volume of cataract surgery,” he said. As such, Dr. Shorstein said Kaiser Permanente’s cataract surgery research group, much like the ASCRS/ASRS Task Force’s recommendation, is advising, although not mandating, its ophthalmologists avoid vancomycin on immediately sequential bilateral cataract surgery (ISBCS) patients. For delayed sequential bilateral cataract surgery, he said the recommendation is to wait at least 4 weeks. Dr. Shorstein said his local group will continue to use cefuroxime as a first line antibiotic prophylaxis and moxifloxacin as a second line if there is an allergy to the first. If in the rare case there is an allergy associated with both, Dr. Shorstein said physicians have 3 choices: not inject an intracameral antibiotic at all (which he does not suggest); inject vancomycin knowing there is a very small risk of HORV; or ask the patient more about his or her allergic reaction to penicillin, and without a history of anaphylaxis, administer cefuroxime since the risk of cross-reactivity is extremely remote. 4 Dr. Shorstein said he thinks there may still be a place for intracameral vancomycin—such as in patients who have a history of infection or colonization with MRSA—and thus, he encourages more research to better understand the mechanism behind the conditions that could be causing HORV. Overall, Dr. Shorstein said his bottom line is that injecting an intracameral antibiotic of some kind is more favorable than not. “Presently, I think patients incur a much higher risk of endophthalmitis if physicians don’t inject any intracameral antibiotic than of getting HORV if they inject intracameral vancomycin.” Richard Kent Stiverson, MD, Kaiser Permanente, Denver Dr. Stiverson said he has used vancomycin since 2006, including in more than 1,750 patients who have had ISBCS since 2013. “The data supporting intracameral antibiotics is impressive in my opinion,” Dr. Stiverson said. Yet in light of recent data regarding vancomycin and HORV, Dr. Stiverson said he will be changing his habits somewhat. “At first, I thought we would be in the clear as we use vancomycin at a lower dose in the irrigation solution, but that is not the case as HORV has been reported with this method as well,” he said. As such, Dr. Stiverson said he