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.


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.


Follow Medscape on Twitter: @Medscape


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.