Hemorrhagic Occlusive Retinal Vasculitis After Intracameral Vancomycin Use in Cataract Surgery After Intravenous Exposure

Abstract

Purpose: To report a case of hemorrhagic occlusive retinal vasculitis after cataract surgery.Methods: A 74-year-old woman presented with blurry vision and distorted vision, which started 2 days after an uncomplicated cataract surgery in the left eye. Intracameral vancomycin was injected during the case. The patient reported being treated with systemic vancomycin in the past.Results: The visual acuity was 20/80 in the left eye. She had trace cells in the anterior chamber with no hypopyon and intraocular lens implant within the capsular bag in the left eye. Dilated fundus examination revealed no vitritis, There were large patches of peripheral retinal hemorrhages and retinal ischemia. The patient was diagnosed with hemorrhagic occlusive retinal vasculitis likely secondary to hypersensitivity reaction to intracameral vancomycin. The patient was started on oral prednisone, and the topical difluprednate course was escalated. Within 3 weeks, vision improved to 20/30 in the left eye. She underwent pan retinal photocoagulation targeting the ischemic areas in the periphery. Conclusion:The patient had previous exposure to systemic vancomycin, which may have sensitized her immune system. Later on, the hypersensitivity reaction took place after exposure to intracameral vancomycin during cataract surgery. Our hemorrhagic occlusive retinal vasculitis case had a favorable visual outcome, and recognition of this entity will ensure that vancomycin will not be used for infection prophylaxis in the fellow eye at the time of cataract surgery.

The Impact of Systemic Medications on Retinal Function

“…Early detection, corticosteroid, and anti-VEGF treatment may improve visual outcomes in select cases 317,321–324. Patients should also be monitored for the development of subsequent neovascular glaucoma.…”

“…Early detection, corticosteroid, and anti-VEGF treatment may improve visual outcomes in select cases. 317,[321][322][323][324] Patients should also be monitored for the development of subsequent neovascular glaucoma. In addition, an increased incidence of CME in these patients has been suggested by some authors.…”

Update on Retinal Drug Toxicities

“…Recent case reports of HORV include that noted in both eyes of a 9-month-old who received intraoperative vancomycin as a routine part of sequential bilateral lensectomies, the first reported case of HORV in a pediatric patient [ 59 ]. Another report of HORV occurred in an elderly patient who underwent cataract surgery with intracameral injection of vancomycin; however, she did have previous exposure to systemic vancomycin for a 6-week course about 21 years ago for a breast implant infection and another one-time dose 1 year prior for a toe infection, and thus the authors wonder whether the prior exposure may have led to sensitization to vancomycin [ 60 ].…”

Vancomycin-associated hemorrhagic occlusive retinal vasculitis masquerading as central retinal vein occlusion

“…Although the ESCRS study was carried out with cefuroxime, vancomycin is one of the most commonly used antibiotics for endophthalmitis prophylaxis because of its safety, availability, and efficacy (5)(6)(7) . However, in the past few years, hemorrhagic occlusive retinal vasculitis (HORV), a rare and dramatic retinal complication related to the intraocular use of vancomycin has been identified (6,8) . Herein, we present a case of unilateral HORV, initially misdiagnosed as central retinal vein occlusion (CRVO).…”