www.medscape.

com

Vancomycin-Related Cataract Surgery Complications

Come Into Focus With Recent Data
Sumit (Sam) Garg, MD

April 20, 2017

Vancomycin-Associated Hemorrhagic Occlusive Retinal Vasculitis: Clinical

Characteristics of 36 Eyes

Witkin AJ, Chang DF, Jumper JM, et al

Ophthalmology. 2017 Jan 19. [Epub ahead of print]

Study Summary

Over the past few years, there has been increasing interest in and study of the use of intracameral
antibiotics at the time of cataract surgery. Although this approach is supported by compelling data, the rare
and vision-threatening occurrence of vancomycin-associated hemorrhagic occlusive retinal vasculitis
(HORV) has also been reported with its use.

This review aimed to understand the causes of HORV and outcomes of patients who experience this
disease.

Characteristic findings of HORV included unremarkable postoperative day 1 undilated fundus examination,
delayed-onset (mean, 8 days), painless vision loss, mild anterior chamber and vitreous inflammation
without hypopyon, sectoral retinal hemorrhages in areas of ischemia (with a predilection for venules),
peripheral retinal involvement in all cases (with macular ischemia in advanced cases), and sectoral retinal
vasculitis and vascular occlusion on fluorescein angiography.

The disease course and findings suggest that HORV is caused by a delayed type III hypersensitivity
reaction to vancomycin.

Early treatment with corticosteroids is probably beneficial. Subsequently, anti-vascular endothelial growth
factor injections and panretinal photocoagulation are important to prevent neovascular glaucoma, a
common complication. Avoidance of additional intravitreal vancomycin is recommended if HORV is
suspected.

In general, these patients have a very poor visual prognosis, and it is the recommendation of both the
American Society of Cataract and Refractive Surgery and American Society of Retina Specialists that
vancomycin be avoided in the second eye of an affected patient.

Viewpoint

Intracameral antibiotic is employed at the time of cataract surgery, with the aim of decreasing the incidence
of postoperative endophthalmitis. Many studies over the past few years have demonstrated the safety and
convenience of intracameral antibiotics to decrease the incidence of endophthalmitis[1,2]; however, it is still
not the standard of care, and not all studies show clear-cut benefit. In addition, there are various protocols
for which medications to use (vancomycin, cefuroxime, and moxifloxacin, among others). Currently, most
ophthalmologists use topical antibiotics as their primary method of prophylaxis against infection.

Although reports such as this one can give us pause, I believe that intracameral antibiotics will be
increasingly used in the United States. With any treatment, there is risk, and we have to ask ourselves
whether the benefits outweigh the risks. In addition, I believe that further study in this area may help us
predict which patients are potentially at higher risk for complications, such as HORV.
Adoption of intracameral antibiotics will probably increase if (and when) there is a commercially available
option. Currently, intracameral antibiotics are mixed by compounding pharmacies or by operating room
staff. However, by administering antibiotics at the time of cataract surgery, you can ensure compliance and
hopefully decrease the devastating complication of postoperative endophthalmitis.

Abstract

Follow Medscape on Twitter: @Medscape

References

1. 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;33:978-988.
2. Packer M, Chang DF, Dewey SH, et al; ASCRS Cataract Clinical Committee. Prevention,
diagnosis, and management of acute postoperative bacterial endophthalmitis. J Cataract Refract
Surg. 2011;37:1699-1714.

Medscape Ophthalmology 2017 WebMD, LLC

Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or
Medscape.

Cite this article: Vancomycin-Related Cataract Surgery Complications Come Into Focus With Recent Data -
Medscape - Apr 20, 2017.