EyeWorld India June 2017 Issue

June 2017 EWAP SECONDARY FEATURE 35 The latest data on vancomycin-associated HORV and where to go from here I n July 2016, ASCRS and the American Society of Retina Specialists (ASRS) formed a joint task force and established a registry to better track, analyze, and understand hemorrhagic occlusive retinal vasculitis (HORV), a rare, sight- threatening condition that appears to occur after uneventful cataract surgery that included intraocular vancomycin prophylaxis. According to the task force’s paper published in Ophthalmology, vancomycin- associated HORV has been Vancomycin-associated HORV: What do we know now? by Liz Hillman EyeWorld Staff Writer AT A GLANCE • Intracameral vancomycin has been associated with a rare but sight-threatening condition known as hemorrhagic occlusive retinal vasculitis (HORV). • Thought to be a Type III delayed hypersensitivity reaction, vision loss often occurs a week or more after uneventful cataract surgery in which intraocular vancomycin was administered. • According to the latest published case series—36 eyes of 23 patients diagnosed with HORV—61% were 20/200 or worse. • The ASCRS/ASRS task force has made several recommendations regarding the use of intracameral vancomycin and treatment of HORV should it develop postop. diagnosed in 36 eyes of 23 patients. 1 The task force describes it as a “potentially devastating condition that can develop after cataract surgery or intraocular injection.” Kevin M. Miller, MD , chief of the cataract and refractive surgery division, David Geffen School of Medicine, University of California, Los Angeles, said the ASCRS/ASRS task force collected eyes with diffuse retinal hemorrhages after surgery— eliminating central retinal vein occlusions (CRVO), which don’t classify as HORV—and collected information about everything that was used at the time of cataract surgery, such as fluids, anesthetic agents, viscoelastic agents, artificial tears, and anything injected into the eye. “All the cases that did fit the criteria had one thing in common, and that was they all had injections of vancomycin,” Dr. Miller said. What’s concerning about this, said Nick Mamalis, MD , professor of ophthalmology, director of ocular pathology, John Moran Eye Center, Salt Lake City, is that the condition is delayed. “As surgeons, we will often do cataract surgery a week apart or maybe even less than that … in rare situations there is even simultaneous bilateral surgery done,” he said. “What’s difficult about this issue is if there is a delay in the onset of signs and symptoms—and it can be a delay of longer than a week, even 2 weeks—then we may not know there is going to be a reaction and then proceed with the second eye. That’s the part that’s really scary about this condition, we don’t see this right away … we may be doing surgery on the second eye before we even know if it is going to occur in the first eye.” How it started The first reported cases of HORV were described between 2014 and 2015, totaling 11 eyes in 6 patients who had uncomplicated cataract surgery and received prophylactic intracameral vancomycin. 2–3 One Vancomycin-associated HORV: What do we know now? Considerations for intraocular vancomycin use • Because HORV appears to be extremely rare, each surgeon should weigh the potential risk of HORV associated with vancomycin against the risk of endophthalmitis. • Reconsider using vancomycin with close sequential bilateral cataract surgery. • Surgeons using intraocular vancomycin with sequential cataract surgery should be aware that in addition to delayed onset, HORV may not cause symptoms in the first eye and a dilated retinal examination may be the only way to detect it. • Surgeons desiring an alternative to vancomycin for intracameral prophylaxis may consider cefuroxime or moxifloxacin.4 Recommendations for management of HORV • Consider avoiding intravitreal vancomycin if both bacterial endophthalmitis and HORV are in the differential. • Consider ocular and/or systemic work-up for other syndromes (e.g. viral retinitis). • Aggressive systemic and topical corticosteroids; consider peri- or intra- ocular steroids • Early anti-VEGF treatment • Early panretinal photocoagulation • If you identify a patient with HORV, please submit the clinical data to the HORV registry site: (links from www.asrs.org or www.ascrs.org) Patient and surgeon names will be kept confidential. Stats from ASCRS/ASRS online HORV Registry 1 • 36 eyes/23 patients diagnosed with HORV • 33/36 received intracameral vancomycin, 1/36 received intravitreal, 2/36 received it through the irrigation bottle • 61% of eyes were 20/200 or worse • 22% had no light perception • Three eyes that received intravitreal corticosteroids were 20/40, 20/70, and hand movements, respectively • 56% of eyes developed neovascular glaucoma • 5/7 eyes that received additional intravitreal vancomycin ended up with no light perception continued on page 36