EyeWorld India September 2016 Issue

September 2016 EWAP FEATURE 19 Richard Mackool, MD, Mackool Eye Institute, Astoria, New York Dr. Mackool uses intracameral vancomycin, and his experience using it has been extremely favorable. He finds that it dramatically reduces the incidence of endophthalmitis to the point of near elimination. At Dr. Mackool’s ASC, he said there have been 80,000 consecutive cataract implant procedures done by 40 surgeons without a single case of endophthalmitis or HORV. Vancomycin virtually eliminates the risk of endophthalmitis, Dr. Mackool said. Whatever the cause of HORV, its incidence is extraordinarily small. “It is not possible to know that incidence, but based upon our experience and unpublished reports from a number of other ASCs, it appears to be 1 in 250,000 eyes or less,” he said. “The extreme rarity of HORV and the effectiveness of vancomycin in preventing endophthalmitis would appear to indicate that the risk/benefit ratio of intracameral vancomycin remains favorable.” Dr. Mackool thinks that the ASCRS/ASRS Clinical Alert represents an appropriate description of the current state of knowledge concerning HORV. “Regarding the question of delaying surgery on the second eye, there is one caveat,” he said. “If significant aniseikonia exists following the first surgery, will continue using vancomycin for unilateral cataract surgery cases with 6 weeks between surgeries. For ISBCS or patients who wish to have unilateral surgery within the 6-week time frame, he will use moxifloxacin. “I think the [ASCRS/ASRS] alert is informative, restrained, and as evidence-based as it can be at this time,” Dr. Stiverson said, adding that there is still very much that is not known about the relationship between HORV and intracameral vancomycin, but “what we do know is profoundly disturbing. I am of the opinion this will ultimately be shown to be vancomycin-induced HORV.” Jeffrey Liegner, MD, Eye Care Northwest, Sparta Township, New Jersey Dr. Liegner said he has used intracameral and intravitreal vancomycin in every case he’s had for the last 3 years, adding it to his practice after perceiving an increased risk of MRSA in his community. He routinely combines vancomycin with moxifloxacin and triamcinolone, a medium strength steroid that remains active inside the eye for 3 weeks postoperatively. “The risk of something versus the benefits of something are carefully weighed by the judicious surgeon, and decisions are made that sometimes embrace risk in exchange for benefit,” he said. “In this situation, vancomycin provides protection against MRSA that is not duplicated by moxifloxacin or [cefuroxime].” Bringing the possible association between intracameral vancomycin use and HORV into the equation caused Dr. Liegner to weigh the risk of HORV compared to the benefit of MRSA prophylaxis. Calling the ASCRS/ASRS Clinical Alert a well-structured and well-formulated document, Dr. Liegner said he is not going to alter his use of vancomycin based on the current knowledge. As of right now, Dr. Liegner said he thinks far more MRSA cases can be prevented with vancomycin use compared to HORV cases that could be prevented without its use. “I think there is a sense of worry out there. As with any profession, there are some individuals who are more inclined to do risk analysis and take risk, and there are others who are profoundly conservative and avoid risk wherever it might be, even if it is in exchange for a different kind of adverse event,” he said. Dr. Liegner also pointed out that it’s not known yet whether this is really a type III hypersensitivity to vancomycin or perhaps a compounding or mixing issue. He said perhaps the patients who developed HORV after intracameral vancomycin could be asked to receive an intradermal vancomycin injection to confirm if it was in fact a type III hypersensitivity reaction to the antibiotic. “Some lost their vision and they already sacrificed their eyes in the worst possible way. Asking them to show us if they have a skin reaction to a drug to implicate whether that’s true or not is a small additional risk,” Dr. Liegner said. “This is a planetary issue, especially with MRSA reaching 80% thresholds in some communities.” depth perception will obviously be negatively affected.” In such cases, the risk of accidents, falls, and other problems can be predicted to increase if greater time is allotted between surgeries, he said. Based on current information, it is not possible to determine if this increased risk is greater than the presumed benefit that may occur if second eye surgery is delayed to evaluate the first eye for possible HORV, Dr. Mackool said. Dr. Mackool said that he will continue to administer vancomycin at the time of intraocular surgery. “The administration of a fourth generation fluoroquinolone has been demonstrated to reduce the incidence of endophthalmitis, but these drugs appear to do so with significantly less efficacy than vancomycin,” he said. EWAP References 1. Nicholson LB, et al. Severe bilateral ischemic retinal vasculitis following cataract surgery. Ophthalmic Surg Lasers Imaging Retina . 2014;45:338–342. 2. Witkin AJ, et al. Postoperative hemorrhagic occlusive retinal vasculitis: Expanding the clinical spectrum and possible association with vancomycin. Ophthalmology . 2015;122:1438–1451. 3. Endophthalmitis Study Group, European Society of Cataract & Refractive Surgeons. Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors. J Cataract Refract Surg . 2007;33:978–88. 4. Wykoff CC, et al. Allergy to povidone-iodine and cephalosporins: the clinical dilemma in ophthalmic use. Am J Ophthalmol . 2011;151:4–6. Editors’ note: The physicians have no financial interests related to their comments. Contact information Liegner : liegner@eyecarenw.com Mackool: mackooleye@aol.com Shorstein : nshorstein@eyeonsight.org Stiverson : richard.stiverson@kp.org