EyeWorld Asia-Pacific September 2018 Issue

57 EWAP PHARMACEUTICALS September 2018 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). There is severe peripheral ischemia in the right eye (C) and complete non- perfusion in the left eye (D) on uorescein angiography. Source: Ryan Terribilini HORV concerns linger for many by Maxine Lipner EyeWorld Senior Contributing Writer What to keep in mind H emorrhagic occlusive retinal vasculitis (HORV) is a dev- astating condition that has left many practition- ers avoiding prophylactic use of vancomycin for cataract surgery. 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 in patients after relative- ly uncomplicated cataract surgery,” Dr. Mamalis said. As practitioners started seeing more of these cases, ASCRS in conjunction with the American Society of Retina Special- ists (ASRS) put together a task force to look into the reports to deter- mine why this was occurring. It started with around six case reports, said Richard Hoffman, MD, clinical associate profes- sor of ophthalmology, Casey Eye Institute, Oregon Health Sciences University, Portland. “After further evaluation and polling, they dis- covered there were at least 36 eyes of 22 patients (with HORV),” Dr. Hoffman said. 1 With this condition, patients appeared fine on the first postoper- ative day. “There’s a delayed onset of painless visual loss with a mild anterior chamber reaction and a mild-to-moderate vitreous inflam- mation,” Dr. Hoffman said. “The patients have retinal hemorrhage that is more pronounced in the peripheral retina with vascular oc- clusion.” 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 glau- coma. “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 all received vancomycin.” This was either in the irrigating bottle, injected 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 endophthalmitis in that the in- flammation is much milder,” he said, adding that there were likely patients who were initially pre- sumed to have endophthalmitis and given intravitreal vancomycin as treatment. “Those eyes did the worst out of all of them,” Dr. Hoff- man said. “There were seven eyes that received additional treatment with vancomycin, and five of them went on to have no light percep- tion vision.” The HORV picture Dr. Mamalis described HORV as a severe hemorrhagic/occlusive vasculitis. “Patients had significant visual continued on page 58