Hemorrhagic Occlusive Retinal Vasculitis
Hemorrhagic occlusive retinal vasculitis (HORV) has been described as a very rare but potentially devastating complication occurring after cataract surgery in which intraocular vancomycin is used. It has a delayed onset and is associated with retinal hemorrhages, vascular nonperfusion, and venous sheathing. The severity appears to be worse when the second eye has undergone cataract surgery in which vancomycin is used.
Visual acuity is typically severely decreased. In the original descriptions by Nicholson et al and Witkin et al , presenting visual acuities were very poor. Patients typically presented 1 to 14 days after successfully cataract surgery. However, patients may present from 1-21 days postoperatively (mean 8 days). Visual acuity outcomes were poor: 4 of 11 eyes were NLP and the others were less than 20/100. A larger series of 23 patients and 36 eyes noted the following characteristic features of HORV:
- Typically postoperative day 1 undilated examination is unremarkable
- Delayed onset vision loss
- Mild anterior chamber and vitreous inflammation
- Sectoral retinal hemorrhages in areas of ischemia
- Predilection for venules and peripheral involvement
Presumed reaction to vancomycin
The primary risk factor appears to be prior intracameral vancomycin during cataract surgery. In the study by Witkin and colleagues, 'All eyes received intraocular vancomycin via intracameral bolus (33/36), via intravitreal injection (1/36), or through the irrigation bottle (2/36).' Visual outcome was especially poor in patients who received additional intravitreal vancomycin for presumed endophthalmitis after surgery (5 of 7 such eyes lost perception of light, one each had 20/800 and 20/400). The fellow eye had a higher risk of HORV and more aggressive disease if intracameral vancomycin was used again as was done in the operated eye. Five of the 23 patients reported by Witkin et al had a documented allergy to penicillin. However, skin testing for hypersensitivity to vancomycin, lidocaine, and viscoelastic were negative in the patients in whom it was performed.
Pathology in 1 patient:
- Chronic nongranulomatous choroiditis (T cells)
- Unusual glomeruloid proliferation of endothelial cells in the choroid and elsewhere in the eye
- No leukocytoclastic vasculitis
Necrotizing retinal vasculopathy, presumed type IV hypersensivitiy reaction (Todorich et al). T-cell mediated process on pathology with intravascular thrombosis.
Avoid sequential cataract surgery with intracameral vancomycin if the fellow eye had HORV
Diagnostic criteria were created by the American Society of Retina Specialists (ASRS) and American Society of Cataract and Refractive Surgeons (ASCRS) Task Force and published by Witkin et al. The anterior segment exam is usually unremarkable on postoperative day 1. Patients complain typically of delayed-onset painless vision loss. At this stage, there is mild anterior chamber and vitreous inflammation, sectoral retinal hemorrhages in areas of ischemia, and a predilection for involvement of venules. A case of bilateral mild HORV has been reported, suggesting that the incidence may be higher than previously thought. 
The diagnostic criteria given by Witkin and colleagues are as follows:
1. Occurs after intraocular procedure with normal undilated examination on postoperative day 1.
2. Delayed onset of sudden painless decreased vision (may be asymptomatic in mild cases).
3. Visual acuity often poor at presentation (may be normal in mild cases).
4. Mild to moderate anterior chamber and vitreous inflammation, with no hypopyon.
5. Sectoral intraretinal hemorrhage in areas of nonperfusion (often along venules).
6. Peripheral retinal involvement in all cases, with macular ischemia in advanced disease.
7. Sectoral retinal vasculitis and vascular occlusion on fluorescein angiography, corresponding to areas of hemorrhage.
Other common associations
1. Use of intraocular vancomycin during procedure.
2. Rapid progression to neovascular glaucoma.
3. History of similar reaction in fellow eye.
4. When both eyes involved, second eye often has faster onset and more severe course.
5. Minimal to no corneal edema.
6. Retinal hemorrhages are often large, confluent, or both.
7. Propensity for retinal venule involvement.
8. No significant increase in venous dilation or tortuosity.
9. Optical coherence tomography findings: hyperreflectivity and thickening of the inner retinal layers.
10. Therapy with additional intravitreal vancomycin associated with especially poor outcomes.
Prior cataract surgery with associated use of vancomycin intraoperatively.
- Normal examination at post-operative day 1.
- On presentation with HORV, mild inflammation is seen with no hypopyon.
- Peripheral sectoral hemorrhages with non-perfusion.
- There may be macular non-perfusion but always peripheral non-perfusion is present.
Decreased painless loss of vision, variable degree.
- Fundus photo shows vasculitis, hemorrhage, and retinal whitening in some cases.
- Fundus fluorescein angiogram shows severe capillary nonperfusion.
- Optical coherence tomography may show inner retinal hyperreflectivity, increased thickness of inner retina, and cystoid macular edema (rare).
- B-scan ultrasonography is needed in cases of media haze due to vitreous hemorrhage.
- Endophthalmitis (in HORV eye is quiet, has no pain, and has only mild posterior uveitis at presentation)
- Viral retinitis (in HORV, the vitritis is mild and there is no progression of retinitis)
- Central retinal venous occlusion (in HORV, the venules are not dilated)
Management and Treatment
- Systemic and topical corticosteroids may help. Early anti-VEGF intravitreous injection and PRP may prevent neovascular glaucoma
- Avoid vancomycin for suspected endophthalmitis
- Avoid vancomycin use in second eye
The recommendations for HORV (by Witkin and colleagues) are as follows:
Considerations for intraocular vancomycin use
- Because HORV seems to be extremely rare, each surgeon should weigh the potential risk of HORV associated with vancomycin against the risk of endophthalmitis.
- Reconsider using vancomycin with close sequential bilateral cataract surgery, especially if immediate sequential same-day bilateral surgery is performed.
- Surgeons using intraocular vancomycin with sequential cataract surgery should be aware that in addition to delayed onset, HORV may not cause symptoms in the first eye, and a dilated retinal examination may be the only way to detect it.
- Surgeons desiring an alternative to vancomycin for intracameral prophylaxis may consider cefuroxime or moxifloxacin. However, it is important to be aware that there has been a rare case report of HORV associated with use of moxifloxacin as well. In addition, retinal toxicity with intracameral cefuroxime has been reported, particularly if a higher concentration is inadvertently used.
Recommendations for management of HORV
- Avoid intravitreal vancomycin if HORV is suspected.
- Consider an ocular or systemic workup, or both, for other syndromes (e.g., viral retinitis) if the diagnosis is unclear.
- Aggressive systemic and topical corticosteroids; consider periocular or intraocular steroids.
- Early anti-VEGF treatment.
- Early panretinal photocoagulation.
- If you identify a patient with HORV, please submit the clinical data to the HORV registry: (links from https://www.surveymonkey.com/r/HORV). Patient and surgeon names will be kept confidential.
Poor visual acuity and rapid progression to neovascular glaucoma which can occur in 56% patients.
ASRS and ASCRS HORV register
The new cases of HORV can be registered at https://www.surveymonkey.com/r/HORV
- Nicholson LB, Kim BT, Jardon J, et al. Severe bilateral ischemic retinal vasculitis following cataract surgery. Ophthalmic Surg Lasers Imaging Retina. 2014;45(4):338-342.
- Witkin AJ, Shah AR, Engstrom RE, et al. Postoperative hemorrhagic occlusive retinal vasculitis: expanding the clinical spectrum and possible association with vancomycin. Ophthalmology. 2015;122(7):1438-1451.
- Witkin AJ, Chang DF, Jumper JM, et al. Vancomycin-Associated Hemorrhagic Occlusive Retinal Vasculitis: Clinical Characteristics of 36 Eyes. Ophthalmology. 2017;124(5):583–595. doi:10.1016/j.ophtha.2016.11.042
- Todorich B. et al. Vancomycin-Associated Hemorrhagic Occlusive Retinal Vasculitis: A Clinical-Pathophysiological Analysis. Am J Ophthalmol 2018;188:131–140.
- Andre J. Witkin, MD, David F. Chang, MD, J. Michael Jumper, MD, Steve Charles, MD, FACS, Dean Eliott, MD, Richard S. Hoffman, MD, Nick Mamalis, MD, Kevin M. Miller, MD, Charles C. Wykoff, MD, PhD. Vancomycin-Associated Hemorrhagic Occlusive Retinal Vasculitis Ophthalmology 2017;124:583-595
- Arepalli S, Modi YS, Deasy R, Srivastava SK. Mild Bilateral Hemorrhagic Occlusive Retinal Vasculitis Following Intracameral Vancomycin Administration in Cataract Surgery. Ophthalmic Surg Lasers Imaging Retina. 2018 May1;49(5):369-373.
- Pan WW, Miller AR, Young BK, Johnson MW, Sassalos TM. Hemorrhagic Occlusive Retinal Vasculitis Associated With Triamcinolone-Moxifloxacin Use During Uncomplicated Cataract Surgery. JAMA Ophthalmol. 2022 Nov 10;141(1):99–101. doi: 10.1001/jamaophthalmol.2022.4697. Epub ahead of print. PMID: 36355355; PMCID: PMC9650624.
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