Postoperative Hemorrhagic Occlusive Retinal Vasculitis

Dean Eliott, MD, was presented with a puzzling case: One week after uneventful cataract surgery, a patient underwent cataract surgery in the second eye. By the next day, her vision had deteriorated to hand movement in 1 eye and light perception in the other, and she had elevated intraocular pressure, corneal stromal edema, and anterior chamber fibrinous reaction. By 1 month postop, the patient had worsened to no light perception in both eyes. At first, Dr. Eliott had no idea of the cause; however, he recalled that this condition was reminiscent of a case that was presented during the Vit Buckle Society meeting years earlier. As it turned out, both cases were examples of hemorrhagic occlusive retinal vasculitis (HORV), a rare and devastating condition linked to the use of intracameral vancomycin.

What we know. HORV typically presents as delayed onset of painless but profound visual loss up to 3 weeks after cataract surgery, said Dr. Eliott on Friday at Retina Subspecialty Day. Anterior chamber findings typically show mild to moderate inflammation without hypopyon. There is peripheral retina involvement in all cases, with large patches of intraretinal hemorrhages, often along the venules.

Poor outcomes. The majority of eyes are worse than 20/200, and neovascular glaucoma is seen in more than 50% of eyes. Early and aggressive steroids (topical, periocular, intraocular, and/or systemic), early anti-VEGF injections, and early panretinal photocoagulation therapy have shown to be helpful in achieving more favorable outcomes.

Is it vancomycin? Ever since the American Society of Retina Specialists and the American Society of Cataract and Refractive Surgery developed a joint task force to further investigate this condition, they have identified 36 eyes of 22 patients with HORV. All had received intracameral vancomycin. HORV is suspected to be a rare type III hypersensitivity to vancomycin; however, its exact cause and pathogenesis remain unproven.

A HORV registry is located at www.asrs.org.—Keng Jin Lee

Financial disclosures: Dr. Eliott: Alcon Laboratories, Inc.: C; Allergan: C; DORC International, bv/Dutch Ophthalmic, USA: C; Neurotech: S; Ocata Therapeutics: S; Ophthotech: C; Santen, Inc.: C.

Disclosure key. C = Consultant/Advisor; E = Employee; L = Speakers bureau; O = Equity owner; P = Patents/Royalty; S = Grant support.