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Raised awareness of HORV yields decreased use of vancomycin

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NEW ORLEANS — Since a report in 2014 of two patients with severe bilateral ischemic retinal vasculitis following cataract surgery, attention has centered on the phenomenon of hemorrhagic occlusive retinal vasculitis in which intracameral vancomycin is the presumed etiological agent.

In 2016, a joint task force of the American Society of Cataract and Refractive Surgery and the American Society of Retina Specialists identified 36 eyes of 23 patients who had received vancomycin during cataract surgery and developed hemorrhagic occlusive retinal vasculitis (HORV), prompting a clinical alert jointly issued by both societies. In these cases, onset occurred within 21 days at a mean of 8 days.

“Almost two-thirds were 20/200 or worse on final exam, and over half developed neovascular glaucoma,” Dean Eliott, MD, said in an update at Retina Subspecialty Day preceding the American Academy of Ophthalmology meeting.

Subsequent cases have been identified, some resulting in better outcomes after treatment with steroids, anti-VEGF and/or panretinal photocoagulation, but is there a definite relationship between vancomycin and HORV?

“I think we can safely say yes,” Eliott said.

Delayed painless visual loss is the typical presentation. Etiology is thought to be a type III hypersensitivity reaction, with exposure sensitizing the patient after the first surgery and triggering an immune response. HORV can present after unilateral surgery or after second eye surgery, even when the second surgery is delayed several years, provided vancomycin is used.

“If vancomycin is not used, the second eye will not develop [HORV],” Eliott said.

“Fortunately, the use of vancomycin during cataract surgery is decreased,” he said. “Please continue to discourage vancomycin use among cataract surgeons.” – by Patricia Nale, ELS

Reference:

Eliott D. Update on hemorrhagic occlusive retinal vasculitis after cataract surgery. Presented at AAO Subspecialty Days; Nov. 10-11, 2017; New Orleans.

Disclosure: Eliott reports no relevant financial disclosures.