EyeWorld India June 2017 Issue

June 2017 36 EWAP SECONDARY FEATURE Views from Asia-Pacific Paisan RUAMVIBOONSUK, MD Rajavithi Hospital Rajavithi Road, Phayatai, Bangkok 10400, Thailand Tel. no. +66-814894455 paisan.trs@gmail.com H emorrhagic occlusive retinal vasculitis (HORV) is a relatively new entity and a severe form of retinal vascular damage due to drug reaction. This newly recognized condition has devastating visual outcome despite treatment. Almost all eyes end up with poor vision. The most important message on HORV may not be diagnosis and treatment of the disease but rather the finding that it is related to one of the most commonly performed procedures in medicine: cataract surgery. It is quite clear now that the condition is related to, in most cases, intracameral vancomycin injection for prophylaxis of endophthalmitis after cataract surgery. HORV should not be confused with retinal toxicity which can occur with other prophylactic drugs, such as aminoglycoside, when inadvertent globe perforation of subconjunctival injection occurs. The recognition of HORV may have brought back controversy of intracameral injection of antibiotics after cataract surgery. It seems justified to avoid the injection because of the possible occurrence of this devastating condition. However, the prevalence of HORV is still rare and it has not yet been found to be associated with intracameral injection of other antibiotics. It is therefore still debatable whether intracameral antibiotic injection should be applied routinely after cataract surgery to reduce endophthalmitis. There is evidence from the literature showing intracameral injection of either cefuroxime or moxifloxacin may significantly reduce endophthalmitis after cataract surgery. While studies on both drugs may be criticized for some limitations, there has not yet been a study supporting intracameral injection of vancomycin for achieving similar outcomes. Unfortunately, either antibiotics for intracameral use is not available in many countries. Vancomycin is selected to be used, mostly in the U.S., because of its practicality to fill this gap. In addition to prophylaxis, treatment of endophthalmitis with intravitreal vancomycin may also result in HORV after the infection has cleared. This apparently was one of the 36 eyes of HORV recently reported. Vancomycin has been widely used for intravitreal injection for many years but there have not yet been other reports on HORV after intravitreal injection. This may be due to either rare prevalence or misdiagnosis of HORV as part of fundus findings of endophthalmitis. If more cases of HORV are found to be associated with intravitreal vancomycin injection in the future, controversy on keeping or avoiding vancomycin for treatment of endophthalmitis will certainly be stirred up as another hot topic in ophthalmology. Editors’ note: Dr. Ruamviboonsuk declared no relevant financial interests. of those patients was referred to Andre Witkin, MD , assistant professor of ophthalmology, Tufts University School of Medicine, Boston. The female patient had uncomplicated bilateral cataract surgery spaced 1 week apart. After a week, she started losing vision in her first eye and was put on steroids by another retina specialist. A week later, her second eye developed similar symptoms. By the time she was referred to Dr. Witkin, she exhibited severe bilateral occlusive retinal vasculitis and diffuse intraretinal hemorrhage. “At the time, we didn’t know what was happening,” Dr. Witkin said. The patient was admitted to the hospital where she had an extensive workup for various infectious diseases or inflammatory conditions—none of which were determined to be the cause of her retinal pathology. None of the tests came back positive. She was treated with high-dose steroids and for a presumptive viral retinitis. In the end, this patient had no light perception in one eye and was 20/200 in her other eye. At the time of this patient’s discharge, Dr. Witkin said an article by Nicholson and colleagues was published describing two other cases that sounded and looked similar to this case. 2 Over time, as these cases were presented at regional and national conferences, other similar cases came out as well. “It seemed like there was mounting evidence that vancomycin may be associated with this disease,” Dr. Witkin said. Intracameral vancomycin use is certainly not new, so why does it seem these HORV cases are occurring only recently? “It’s so rare that I think people didn’t recognize it, and I think some HORV was treated as endophthalmitis,” Dr. Miller said. “Other HORV was probably brushed off as an unfortunate postoperative central vein occlusion. I think it’s when the cases started appearing bilaterally that it became clear it wasn’t these other things.” Signs, symptoms, and etiology According to David Chang, MD , clinical professor, University of California, San Francisco, and private practice in Los Altos, California, there is a delayed but sudden onset of painless, decreased vision, usually around 1 to 3 weeks postop, though it can occur earlier. Dr. Mamalis pointed out that unlike a toxicity reaction, which would present immediately, the patients who experienced HORV after intracameral vancomycin developed symptoms later, suggesting an immune reaction. If the second eye also has surgery with intraocular vancomycin, Dr. Chang, co-chair of the ASCRS/ASRS HORV task force, noted that the onset of HORV is often earlier and more severe than it was in the first. Conversely, if the second eye did not receive vancomycin, it had a normal outcome. Seven eyes in the latest dataset received an additional bolus of vancomycin Vancomycin – from page 35