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Link between vancomycin and HORV illuminated
With the link between vancomycin and HORV being clearer, clinicians must weigh risks and consider using other antibiotics.
Clinicians should now accept that intraocular vancomycin can cause hemorrhagic occlusive retinal vasculitis, according to a speaker at Hawaiian Eye 2017.
Given the increasing obvious association between vancomycin and hemorrhagic occlusive retinal vasculitis (HORV), David F. Chang, MD, urged colleagues to weigh this risk if choosing an intracameral antibiotic for endophthalmitis prophylaxis.
“I think each of us has to individually weigh this risk of HORV against the risk of endophthalmitis that would not have been prevented by another antibiotic besides vancomycin,” he said.
In giving an updated report of findings from the joint ASCRS/ASRS HORV Task Force that he co-chairs, Chang said that the number of patients known to experience HORV after receiving intraocular vancomycin has grown to 23 and includes 36 eyes, with some cases dating back 10 years. Thirteen of the patients suffered HORV bilaterally.
“As hard as we tried to find a single case of HORV without vancomycin exposure, we haven’t yet identified one,” Chang said. Most cases resulted from intracameral injection, some from intravitreal injection and one from vancomycin in the irrigating bottle.
Clinical course
In some patients, painless but severe vision loss was delayed up to 21 days (mean 8 days) after surgery, which was problematic in patients whose second eye was operated soon after the first because surgeons did not become aware of HORV in the first eye until after the second eye had also received vancomycin.
“I think that bilateral blindness due to HORV has now assumed the mantle of the worst complication that can happen to a cataract patient,” Chang said.
Follow-up exams ranging from 2 months to 10 years postoperatively revealed visual acuity in 22 eyes (61%) was 20/200 or worse, in eight eyes (22%) was no light perception and in six eyes (17%) was 20/40 or better.
“And this is very sobering: 56% of the cases went on to neovascular glaucoma very, very quickly,” Chang said.
Seven cases received a subsequent intravitreal injection of vancomycin that was given for suspected endophthalmitis. These eyes had poor outcomes with visual acuity of no light perception in five eyes, 20/400 in one eye and 20/800 in one eye. Retina specialists should therefore not administer intravitreal vancomycin if HORV is suspected, Chang said.
Patients can also be asymptomatic if the retinal vasculitis is confined to the periphery, Chang explained, and a dilated fundus exam may be necessary to diagnose mild HORV.
ASRS recommendations for treatment include consideration of systemic and intraocular steroids, along with early anti-VEGF therapy and early panretinal photocoagulation, he said. Chang noted that surgeons should report new HORV cases to the registry established by the American Society of Retina Specialists and the American Society of Cataract and Refractive Surgery at either www.asrs.org or www.ascrs.org.
“The registry is meant to provide a permanent reporting mechanism so we can track and learn more about [HORV],” Chang said.
Chang discussed alternatives to vancomycin for intracameral antibiotic prophylaxis, including moxifloxacin. He cited a paper that he co-authored that assessed 116,714 eyes that underwent cataract surgery between February 2014 and April 2015 at the Aravind Eye Hospital in Madurai, India. Routine intracameral moxifloxacin prophylaxis achieved a fourfold reduction in postoperative endophthalmitis in eyes undergoing manual small incision cataract surgery (P < .0001). An expanded study involving all 10 regional Aravind eye hospitals in Tamil Nadu, India, looked at more than 600,000 consecutive cataract surgeries during a 29-month period and also found intracameral moxifloxacin prophylaxis to be efficacious.
Chang said that American surgeons have the option of using the unpreserved topical Vigamox formulation off label or a compounding pharmacy as a source for intracameral moxifloxican injection. – by Joe Green
- References:
- Aravind H, et al. Ophthalmology. 2016;doi:10.1016/j.ophtha.2015.09.037.
- Chang DF. Intracameral antibiotic prophylaxis: The nightmare of HORV. Presented at: Hawaiian Eye; Jan. 16-20, 2017; Koloa, Hawaii.
- For more information:
- David F. Chang, MD, can be reached at 762 Altos Oaks Drive, Suite 1, Los Altos, CA 94024; email: dceye@earthlink.net.
Disclosure: Chang reports no relevant financial disclosures.