July 2016




Opinions on intracameral antibiotics and ASCRS/ASRS alert

by Liz Hillman EyeWorld Staff Writer


Experts weigh in on recommendations regarding rare but strong association between HORV cases and intracameral vancomycin

Following the first published data showing a possible association with intraocular vancomycin use and postoperative hemorrhagic occlusive retinal vasculitis (HORV),1,2 ASCRS and the American Society of Retina Specialists (ASRS) formed a joint Task Force to investigate, make recommendations, and establish an HORV registry to collect more information. In its Clinical Alert (see page 17 of this issue of EyeWorld), the Task Force states that while the cause of HORV is currently unproven, there is a strong association with the use of intraocular vancomycin. There are still many unknowns regarding intraocular vancomycin and rare cases of HORV. Coupled with the proven benefits of using the antibiotic to reduce risk of endophthalmitis, there are various opinions on both. EyeWorld spoke with a few physicians about the Clinical Alert and their own takes on the topic.

Neal Shorstein, MD

Neal Shorstein, MD, Kaiser Permanente, Walnut Creek, California

Intracameral cefuroxime was the first line endophthalmitis prophylaxis for Dr. Shorsteins group nearly a decade ago based on findings from the multicenter, randomized control trial by the European Society of Cataract & Refractive Surgeons.3

But 15% of their patients were allergic to penicillin or cephalosporin, making them suboptimal candidates for cefuroxime. In these patients, Dr. Shorstein said they started using moxifloxacin. Even then though, 1% of patients were allergic to both classes of drugs. These patients received intracameral vancomycin. We knew we wanted to give an intracameral antibiotic to 100% of patients so we started with cefuroxime because that had the best evidence. That has always been our default drug; we havent changed from that. Moxi was the second line and vanco was the third line, Dr. Shorstein said. In light of the recent information regarding rare cases of HORV and intracameral vancomycin, Dr. Shorstein said, based on the annual volume of cataract surgeries in Kaiser Permanentes Northern California system, which is more than 38,000 a year, we had to weigh the risks and benefits. In a recent study, we found that the organisms that cause endophthalmitis in our system were most sensitive to vancomycin. On the other hand, whereas a single ophthalmologist practicing in the United States may never experience HORV if he or she continues to use vancomycin, the chances of a large group like ours finally encountering a case of HORV is higher because of our annual volume of cataract surgery, he said. As such, Dr. Shorstein said Kaiser Permanentes cataract surgery research group, much like the ASCRS/ASRS Task Forces recommendation, is advising, although not mandating, its ophthalmologists avoid vancomycin on immediately sequential bilateral cataract surgery (ISBCS) patients. For delayed sequential bilateral cataract surgery, he said the recommendation is to wait at least 4 weeks. Dr. Shorstein said his local group will continue to use cefuroxime as a first line antibiotic prophylaxis and moxifloxacin as a second line if there is an allergy to the first. If in the rare case there is an allergy associated with both, Dr. Shorstein said physicians have 3 choices: not inject an intracameral antibiotic at all (which he does not suggest); inject vancomycin knowing there is a very small risk of HORV; or ask the patient more about his or her allergic reaction to penicillin, and without a history of anaphylaxis, administer cefuroxime since the risk of cross-reactivity is extremely remote.4 Dr. Shorstein said he thinks there may still be a place for intracameral vancomycinsuch as in patients who have a history of infection or colonization with MRSAand thus, he encourages more research to better understand the mechanism behind the conditions that could be causing HORV. Overall, Dr. Shorstein said his bottom line is that injecting an intracameral antibiotic of some kind is more favorable than not. Presently, I think patients incur a much higher risk of endophthalmitis if physicians dont inject any intracameral antibiotic than of getting HORV if they inject intracameral vancomycin.

Richard Kent Stiverson, MD

Richard Kent Stiverson, MD, Kaiser Permanente, Denver

Dr. Stiverson said he has used vancomycin since 2006, including in more than 1,750 patients who have had ISBCS since 2013. The data supporting intracameral antibiotics is impressive in my opinion, Dr. Stiverson said. Yet in light of recent data regarding vancomycin and HORV, Dr. Stiverson said he will be changing his habits somewhat. At first, I thought we would be in the clear as we use vancomycin at a lower dose in the irrigation solution, but that is not the case as HORV has been reported with this method as well, he said. As such, Dr. Stiverson said he will continue using vancomycin for unilateral cataract surgery cases with 6 weeks between surgeries. For ISBCS or patients who wish to have unilateral surgery within the 6-week time frame, he will use moxifloxacin. I think the [ASCRS/ASRS] alert is informative, restrained, and as evidence-based as it can be at this time, Dr. Stiverson said, adding that there is still very much that is not known about the relationship between HORV and intracameral vancomycin, but what we do know is profoundly disturbing. I am of the opinion this will ultimately be shown to be vancomycin-induced HORV.

Jeffrey Liegner, MD

Jeffrey Liegner, MD, Eye Care Northwest, Sparta Township, New Jersey

Dr. Liegner said he has used intracameral and intravitreal vancomycin in every case hes had for the last 3 years, adding it to his practice after perceiving an increased risk of MRSA in his community. He routinely combines vancomycin with moxifloxacin and triamcinolone, a medium strength steroid that remains active inside the eye for 3 weeks postoperatively.

The risk of something versus the benefits of something are carefully weighed by the judicious surgeon, and decisions are made that sometimes embrace risk in exchange for benefit, he said. In this situation, vancomycin provides protection against MRSA that is not duplicated by moxifloxacin or [cefuroxime]. Bringing the possible association between intracameral vancomycin use and HORV into the equation caused Dr. Liegner to weigh the risk of HORV compared to the benefit of MRSA prophylaxis. Calling the ASCRS/ASRS Clinical Alert a well-structured and well-formulated document, Dr. Liegner said he is not going to alter his use of vancomycin based on the current knowledge. As of right now, Dr. Liegner said he thinks far more MRSA cases can be prevented with vancomycin use compared to HORV cases that could be prevented without its use. I think there is a sense of worry out there. As with any profession, there are some individuals who are more inclined to do risk analysis and take risk, and there are others who are profoundly conservative and avoid risk wherever it might be, even if it is in exchange for a different kind of adverse event, he said. Dr. Liegner also pointed out that its not known yet whether this is really a type III hypersensitivity to vancomycin or perhaps a compounding or mixing issue. He said perhaps the patients who developed HORV after intracameral vancomycin could be asked to receive an intradermal vancomycin injection to confirm if it was in fact a type III hypersensitivity reaction to the antibiotic. Some lost their vision and they already sacrificed their eyes in the worst possible way. Asking them to show us if they have a skin reaction to a drug to implicate whether thats true or not is a small additional risk, Dr. Liegner said. This is a planetary issue, especially with MRSA reaching 80% thresholds in some communities.

Richard Mackool, MD

Richard Mackool, MD, Mackool Eye Institute, Astoria, New York

Dr. Mackool uses intracameral vancomycin, and his experience using it has been extremely favorable. He finds that it dramatically reduces the incidence of endophthalmitis to the point of near elimination. At Dr. Mackools ASC, he said there have been 80,000 consecutive cataract implant procedures done by 40 surgeons without a single case of endophthalmitis or HORV. Vancomycin virtually eliminates the risk of endophthalmitis, Dr. Mackool said. Whatever the cause of HORV, its incidence is extraordinarily small. It is not possible to know that incidence, but based upon our experience and unpublished reports from a number of other ASCs, it appears to be 1 in 250,000 eyes or less, he said. The extreme rarity of HORV and the effectiveness of vancomycin in preventing endophthalmitis would appear to indicate that the risk/benefit ratio of intracameral vancomycin remains favorable. Dr. Mackool thinks that the ASCRS/ASRS Clinical Alert represents an appropriate description of the current state of knowledge concerning HORV. Regarding the question of delaying surgery on the second eye, there is 1 caveat, he said. If significant aniseikonia exists following the first surgery, depth perception will obviously be negatively affected. In such cases, the risk of accidents, falls, and other problems can be predicted to increase if greater time is allotted between surgeries, he said. Based on current information, it is not possible to determine if this increased risk is greater than the presumed benefit that may occur if second eye surgery is delayed to evaluate the first eye for possible HORV, Dr. Mackool said.

Dr. Mackool said that he will continue to administer vancomycin at the time of intraocular surgery. The administration of a fourth generation fluoroquinolone has been demonstrated to reduce the incidence of endophthalmitis, but these drugs appear to do so with significantly less efficacy than vancomycin, he said.


1. Nicholson LB, et al. Severe bilateral ischemic retinal vasculitis following cataract surgery. Ophthalmic Surg Lasers Imaging Retina. 2014;45:338342.

2. Witkin AJ, et al. Postoperative hemorrhagic occlusive retinal vasculitis: Expanding the clinical spectrum and possible association with vancomycin. Ophthalmology. 2015;122:14381451.

3. 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;33:97888.

4. Wykoff CC, et al. Allergy to povidone-iodine and cephalosporins: the clinical dilemma in ophthalmic use. Am J Ophthalmol. 2011;151:46.

Editors note: The physicians have no financial interests related to their comments.

Contact information

: liegner@eyecarenw.com
Mackool: mackooleye@aol.com
Shorstein: nshorstein@eyeonsight.org
Stiverson: richard.stiverson@kp.org

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Opinions on intracameral antibiotics Opinions on intracameral antibiotics
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