EyeWorld Asia-Pacific September 2018 Issue

58 EWAP PHARMACEUTICALS September 2018 loss,” he said. “They had a tremen- dous amount of inflammation, and it was all associated with the vessels that were in the retina causing widespread hemorrhages and widespread disturbances of the vessels. It was causing an oc- clusive vasculitis, and we hadn’t seen this before.” Cases of HORV are typically diagnosed by the characteristics and by the temporal relation- ship to the cataract surgery. The delayed onset inflammation makes it unique. “Oftentimes, when we see patients with inflammation after cataract surgery, it’s acute,” Dr. Mamalis said, adding that such immediate reactions are usu- ally associate with toxic anterior segment syndrome (TASS), which occurs acutely in the anterior seg- ment. However, this was different because it arose posteriorly in the retina and took place 1–2 weeks after the initial cataract surgery in cases that involved the use of vancomycin. Dr. Hoffman stressed that HORV is a devastating but very rare condition. “They tended to be bilateral, so they received surgery in one eye and the problem was that this either had a very mild vasculitis or hadn’t even devel- oped when they received surgery in the second eye,” he said, adding that this resulted in bilateral dis- ease of varying severity. To determine if a case might be HORV requires the use of indi- rect ophthalmoscopy, Dr. Hoffman explained. If you look at the back of the eye, you see peripheral mas- sive hemorrhages that look like a vasculitis involving the venules. “There’s ischemia of the veins and massive hemorrhages that’s more pronounced in the periphery and just a mild cellular reaction,” Dr. Hoffman said. The distinct clinical onset of HORV sets it apart. For instance, endophthalmitis has a severe cellular reaction with pain and a severe anterior chamber re- action; by contrast HORV patients have a mild anterior reaction and no pain. Anyone with visual loss and fairly massive peripheral hemor- rhages who has received vancomy- cin either in the irrigating solution or as a bolus should be considered a suspect for having the condition, Dr. Hofman said. “So far, we don’t have any cases that are confirmed HORV that haven’t received vanco- mycin,” he said. Looking at vancomycin use Despite the HORV risk, there are still some surgeons using vanco- mycin, Dr. Hoffman noted, adding that because the condition is rare, the paper the task force published did not recommend completely eliminating vancomycin use. “For instance, if you have a patient with MRSA, vancomycin is an ideal medication,” he said. “So there are still surgeons who are using it. In the paper we didn’t recommend they stop using van- comycin, but the surgeon needs to weigh the rare risk of HORV with the risk of endophthalmitis.” Retina surgeons are still us- ing vancomycin in combination with a gram-negative antibiotic for treating endophthalmitis. “In confirmed or highly suspicious endophthalmitis, I think that’s still being used,” Dr. Hoffman said. “This is extremely rare, so the chances that a retina surgeon is going to create HORV is rare and worth the risk of using vancomy- cin in that situation.” Even prophylactically, some are still using it. “I think there are still some surgeons who use vanco- mycin because they think it’s bet- ter than moxifloxacin or cefuroxi- me, which are the other antibiotics commonly used,” he said. “They think that the risk is relatively low.” In such cases, Dr. Hoffman advised that if vancomycin is used, patients should undergo a dilated fundus examination after the first eye to make sure they’re not developing HORV before they have vancomycin injected into the second eye. “There’s also a debate about whether or not it’s a good idea to do eyes very close together,” Dr. Hofman said, adding that some may do one eye and do the second with vancomycin 1 week later. There are even some surgeons who are doing bilateral simultane- ous cataract surgery. “I think that it would not be wise to be using vancomycin in those patients because you don’t know if they’re 1 in 1 million until you’ve injected both of their eyes,” Dr. Hoffman said. “There were some prominent surgeons who were using it and have done thousands of cases with intracameral vancomycin, never had a problem, and decided that it wasn’t worth it.” Dr. Mamalis said that since the task force report has come out there has been a decrease in the HORV concerns – from page 57