Endophthalmitis After Cataract Surgery: An Update on Recent Advances

Travis J. Peck; Samir N. Patel; Allen C. Ho


Curr Opin Ophthalmol. 2021;32(1):62-68. 

In This Article

Hemorrhagic Occlusive Retinal Vasculitis and Intracameral Vancomycin

As stated above, vancomycin was the most commonly used intracameral antibiotic at the time of cataract surgery among ASCRS respondents in 2014. This was likely the result of availability, safety, and desirable antibacterial profile.[19] As the result of numerous cases of retinal vasculitis reported after cataract surgery in 2014 and 2015, the ASCRS and American Society of Retinal Specialists (ASRS) formed a joint committee entitled the hemorrhagic occlusive retinal vasculitis (HORV) task force to investigate the cause.[20] A total of 36 eyes met diagnostic criteria for HORV, and 100% of these eyes received intracameral vancomycin at the time of surgery.[20] It was also found that, for patients who underwent bilateral cataract surgery but only received vancomycin in one eye, HORV developed only in the eye receiving vancomycin.[20] Thus, it is believed that intracameral vancomycin may rarely incite a potentially devastating retinal vasculitis that presents a median of eight days after cataract surgery.[20]

The mechanism of HORV remains somewhat unclear. Initially thought to be a form of leukocytoclastic retinal vasculitis, it appears now to be the result of a drug-induced immune-mediated microangiopathy.[21] Recent histopathologic study of an eye with HORV found a T-cell predominance of inflammatory cells, suggesting a type IV hypersensitivity reaction similar to Stevens–Johnson syndrome.[21] Vancomycin is a known inciting agent for cutaneous Stevens–Johnson syndrome;[22] however, it is unclear why the manifestations of HORV would be limited to the eye. The authors of this study also note that the inflammatory cells were limited to the choroid with overlying retinal necrosis without retinal vasculitis.[21] Thus, they propose that a more appropriate name would be hemorrhagic occlusive choroidal and retinal vasculopathy.[21]