EyeWorld Asia-Pacific September 2018 Issue

September 2017 3 EWAP EDITORIAL 8 EYEWORLD ASIA-PACIFIC EDITORIAL BOARD C HIEF MEDICAL EDITOR Graham BARRETT, Australia MEMBERS Abhay VASAVADA, India CHAN Wing Kwong, Singapore CHEE Soon Phaik, Singapore Hiroko BISSEN-MIYAJIMA, Japan Hungwon TCHAH, South Korea ASIA-PACIFIC CHINA EDITION Regional Managing Editor YAO Ke Deputy Regional Editors HE Shouzhi ZHAO Jialiang Assistant Editors SHENTU Xing-chao ZHOU Qi ASIA-PACIFIC INDIA EDITION Regional Managing Editor S. NATARAJAN Deputy Regional Editor Abhay VASAVADA ASIA-PACIFIC KOREA EDITION Regional Managing Editor Hungwon TCHAH Deputy Regional Editor Chul Young CHOI John CHANG, Hong Kong Johan HUTAURUK, Indonesia Kimiya SHIMIZU, Japan Pannet PANGPUTHIPONG, Thailand Ronald YEOH, Singapore S. NATARAJAN, India Sri GANESH, India YAO Ke, China Y.C. LEE, Malaysia Challenging Cases Graham Barrett Chief Medical Editorial EyeWorld Asia-Paci c T he current issue of EyeWorld Asia-Pacific discusses many of the challenging cases and potential complications encountered in cataract and refractive surgery. The most serious potential complication, however, remains endophthalmitis following cataract surgery and one of the articles addresses recent concerns regarding the association of hemorrhagic occlusive retinal vasculitis (HORV) with intracameral vancomycin. Intracameral vancomycin has proved to be one of the most effective antibiotics for the prevention of endophthalmitis for several decades but understandably recent reports of HORVs has led many surgeons to consider alternative antibiotics. The most popular alternative intracameral antibiotics include cefuroxime, which was found to be effective in a randomized prospective controlled study conducted by ESCRS, and moxifloxacin. A retrospective study of the latter in 600,000 eyes in India showed a 3.5-fold reduction in the incidence of endophthalmitis. Commercial cefuroxime for intracameral use (Aprokam Theo Pharmaceuticals, UK) is available in Europe and moxifloxacin compounded for intraocular uses (Oromax, Orolab, India) is available in India and several other countries. Nevertheless, in several countries including Australia, these commercial preparations are unavailable. Compounding an appropriate solution of moxifloxacin from available IV preparations is challenging due to the low pH of moxifloxacin and disappointingly cefuroxime is not available in Australia. Cefazolin is widely used in some countries as an alternative but current evidence suggests that cefazolin may not be an ideal choice. We looked at the antibiotic sensitivity of endophthalmitis cases isolated between 2008 and 2017 in Perth, Western Australia, and only 46.5% were sensitive to the cefazolin as opposed to 100% sensitive to vancomycin and 89.8% sensitive to quinolones. To the best of my knowledge, only 39 eyes diagnosed with HORV have ever been reported despite the extensive use of vancomycin over more than two decades. In addition, the sole patient reported with HORV in which vancomycin was administered via intraoperative infusion had a subclinical presentation not requiring treatment with an excellent outcome. There is a risk associated with the administration of any intracameral antibiotic as well as the potential for TASS when these preparations are prepared in the OR. Considering that the reported risk of HORV with a low dose of vancomycin administered in the infusion appears to be less than when used as an intracameral bolus, the use of vancomycin in the former manner appears reasonable until suitable preparations with a comparable sensitivity profile become available. EWAP “ Considering that the reported risk of HORV with a low dose of vancomycin administered in the infusion appears to be less than when used as an intracameral bolus, the use of vancomycin in the former manner appears reason- able until suitable preparations with a comparable sensi- tivity profile become available. ” –Graham Barrett, MD