Severe Bilateral Ischemic Retinal Vasculitis Following Cataract Surgery

Abstract

This report describes two cases of severe, bilateral ischemic retinal vasculitis following cataract surgeries at different surgical centers. In both cases, the patient underwent bilateral cataract surgeries, performed 1 week apart for each eye. In the perioperative period following the second of the two surgeries, both patients developed severe, bilateral intraocular inflammation and profound vision loss. The underlying cause of this adverse response remains unknown. The authors suggest that the severe inflammatory reaction could be related to an intraoperative intracameral vancomycin injection.

The best of the best: a review of select retina case reports published in 2015

“…First described in 2 patients (4 eyes) by Nicholson et al in 2014, 1 HORV presents as a severe hemorrhagic vasculitis several days to several weeks postoperatively. Fluorescein angiography can reveal dramatic peripheral nonperfusion from occlusive vasculitis.…”

Haemorrhagic occlusive retinal vasculitis associated with intracameral vancomycin during cataract surgery

“…Interestingly, similar presentations in six patients have since been reported across multiple centres in the United States, all of which were observed to be associated with one common variable—intraoperative use of intracameral vancomycin (1 mg/0.1 mL). Collectively they have been recognized as a syndrome of post‐operative haemorrhagic occlusive retinal vasculitis (HORV), where intracameral vancomycin is hypothesized to be the offending agent, and consists of the following characteristics: recent cataract surgery subacute onset after surgery(1 to 14 days) painless visual loss mild to moderate anterior and intermediate uveitis diffuse occlusive retinal vasculitis with predilection for venules extensive intraretinal haemorrhages in ischaemic regions negative ocular and systemic work‐up …”

“…Direct toxicity of intracameral vancomycin has been considered less likely to be the cause of HORV as most eyes were not affected immediately after instillation . Instead, Witkin et al postulated that Type III hypersensitivity (antibody mediated) reaction to intracameral vancomycin may occur in the small blood vessels of the eye.…”

“…This reasoning is supported by particularly poor visual outcomes in eyes which were treated with intravitreal vancomycin for suspected bacterial endophthalmitis, as it would be expected to exacerbate the underlying process. In addition, intracameral steroid given by our patient's surgeon at the time of surgery may explain the less severe retinal signs and relatively better outcome in this case based on the above‐mentioned hypothesis.…”

Intracameral antibiotic: the Vancomycin conundrum

“…It characterised by anterior chamber and vitreous cells, extensive retinal haemorrhages and ischaemic vasculitis. This ophthalmic complication has come to light since 2013 . Vancomycin use is common to all the HORV cases.…”