EyeWorld Asia-Pacific December 2017 Issue

The latest on intracameral antibiotics Dr. Chang discusses intracameral antibiotics at the 2017 ASCRS•ASOA Symposium & Congress. Source: ASCRS 52 December 2017 EWAP CATARACT/IOL David F. Chang, MD presented new information on intracameral antibiotics at the 2017 ASCRS•ASOA Symposium & Congress T he use of intraocular antibiotic prophylaxis following cataract sur- gery has been increasing, according to a presentation given by ASCRS Cataract Clinical Com- mittee member David F. Chang, MD , Los Altos, California, at the 2017 ASCRS•ASOA Symposium & Congress. According to two ASCRS member surveys conducted by the Cataract Clinical Commit- tee, the percentage of surgeons using routine intraocular antibi- otic prophylaxis increased from 30% in 2007 to 50% in 2014. 1,2 Of those using intraocular anti- biotics, 84% were doing so with a direct intracameral (IC) injection, compared to 52% in 2007. Among the respondents using an intraoc- ular antibiotic, 37% overall (and 52% of American respondents) were using vancomycin; moxi- floxacin 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 vasculitis (HORV) to intraocular vancomycin. 3 The HORV Task Force is a joint effort between AS- CRS and the American Society of Retina Specialists (ASRS), created on the heels of the first pub- lished retrospective case series of HORV in 11 eyes of six patients, to advance understanding of the prevalence, etiology, treatment, and outcomes of HORV associ- ated 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 re- garding potential cases of HORV in their practices. In addition to a comprehensive literature search, the Task Force members conferred with immunologists and pub- lished 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 dif- ferent doses, routes of adminis- tration, manufacturers, and with different adjuvants. All cases followed uncomplicated cataract surgery and were characterized by delayed onset (range 1–26 days postoperatively; mean 8 days) of sudden, painless decreased vision. Visual acuity was com- monly 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 in- volvement with macular ischemia and whitening in advanced cases, sectoral retinal vasculitis, and retinal vascular occlusion on FA (corresponding to areas of hemor- rhage). 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). Neo- vascular glaucoma was demon- strated in 20 eyes (56%), which was characterized by rapid onset and progression. Five of seven eyes that received additional intravitreal vancomycin for pre- sumed endophthalmitis resulted in NLP vision. In the 26 documented bilat- eral eyes (13 patients), the absence of immediate adverse events fol- lowing surgery caused surgeons to proceed to second eye surgery, ultimately leading to bilateral HORV. Fellow eye reactions had a faster onset and more severe clini- cal course than in the first eye, consistent with type 3 hypersen- sitivity reactions. Unfortunately, no method exists to test for type 3 hypersensitivity reactions either pre- or post-HORV diagnosis. “We certainly think you should re- consider 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 initially 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 routine intracameral vancomycin for 18 years without any known cases of HORV. However, follow- ing 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 performed at little or no cost on charity pa- tients using sutureless, manual small incision cataract surgery (MSICS). This technique involves continued on page 54