Hemorrhagic occlusive retinal vasculitis (HORV) is a rare complication of cataract surgery using which intraocular agent?

Vancomycin HORV is described as a very rare but potentially devastating complication of cataract surgery in which intraocular vancomycin is used.

Over what postoperative interval does hemorrhagic occlusive retinal vasculitis typically present?

1 to 21 days, mean 8 days Patients may present from 1 to 21 days postoperatively with a mean of 8 days; the original series described presentation 1 to 14 days after surgery.

Which combination of findings is characteristic of hemorrhagic occlusive retinal vasculitis?

Retinal hemorrhages, vascular nonperfusion and venous sheathing HORV has a delayed onset and is associated with retinal hemorrhages, vascular nonperfusion and venous sheathing.

Dense hypopyon with severe vitreous exudate

Macular hole with epiretinal membrane formation

Bullous serous detachment with choroidal folds

Which feature helps distinguish hemorrhagic occlusive retinal vasculitis from postoperative endophthalmitis?

Only mild anterior chamber and vitreous inflammation HORV shows only mild anterior chamber and vitreous inflammation, unlike the marked reaction of endophthalmitis; the case described a reaction not suggestive of endophthalmitis.

Marked corneal oedema with fibrin membrane

Rapid onset within 24 hours of surgery

Normal fluorescein angiogram in the periphery

Where are the retinal hemorrhages of hemorrhagic occlusive retinal vasculitis characteristically located?

Sectoral, in areas of ischemia with peripheral predilection Characteristic features include sectoral retinal hemorrhages in areas of ischemia, with a predilection for venules and peripheral involvement.

Confined strictly to the posterior pole

In a diffuse dot-and-blot pattern in all quadrants

Only along the superior arcade near the disc

What does fundus fluorescein angiography typically demonstrate in hemorrhagic occlusive retinal vasculitis?

Severe capillary nonperfusion Fundus fluorescein angiography in HORV shows severe capillary nonperfusion; the reported case also had delayed retinal filling and perivascular staining.

Smokestack leakage at the posterior pole

Normal transit with late disc hyperfluorescence

Silent choroid with dark background

Which optical coherence tomography changes may be seen in hemorrhagic occlusive retinal vasculitis?

Inner retinal hyperreflectivity and increased inner retinal thickness OCT may show inner retinal hyperreflectivity and increased inner retinal thickness, with cystoid macular edema being rare.

Subretinal drusenoid deposits with RPE atrophy

Outer retinal tubulation with choroidal thickening

Vitreomacular traction with a lamellar hole

Why should a dilated retinal examination be performed on the first eye before sequential cataract surgery?

HORV may be present in the first eye without symptoms Besides its delayed onset, HORV may cause no symptoms in the first eye, so dilated retinal examination may be the only way to detect it before operating on the second eye.

Vancomycin causes reversible corneal deposits

Posterior capsule opacity develops within one week

Intraocular pressure spikes are common by day seven

Which alternatives to vancomycin are suggested for intracameral prophylaxis in cataract surgery?

Cefuroxime or moxifloxacin Surgeons wanting an alternative to vancomycin for intracameral prophylaxis may consider cefuroxime or moxifloxacin.

Which treatments are recommended to prevent neovascular glaucoma in hemorrhagic occlusive retinal vasculitis?

Early anti-VEGF injection and panretinal photocoagulation Alongside aggressive systemic and topical corticosteroids, early anti-VEGF injection and early panretinal photocoagulation may prevent neovascular glaucoma; intravitreal vancomycin should be avoided.

Repeat intravitreal vancomycin and oral antivirals

Topical beta-blockers with observation alone

Immediate pars plana vitrectomy with silicone oil

Hemorrhagic Occlusive Retinal Vasculitis (HORV): full report

CASE REPORT

A 51-year-old healthy female underwent uneventful cataract surgery in her right eye. During the procedure, viscoelastic and vancomycin (1.0 mg/0.2 mL) were injected into the anterior chamber.

Visual acuity on the first postoperative day was 20/20 and no other postoperative complication was detected. On the seventh postoperative day, the patient complained of acute painful visual deterioration. Visual acuity was 20/32 in her right eye with the minimal anterior chamber and vitreous reaction, not suggestive of endophthalmitis.

She was referred to a clinic 2 days later (post-op 9 days) for further investigation. Ophthalmic examination revealed best corrected visual acuity of 20/32 and 20/25 in the right and left eye respectively. Intraocular pressure was 15 mmHg in both eyes, and pupil reaction was normal.

A slit lamp examination of the right eye revealed 1+ cell in the anterior chamber and 1+ cell in the anterior vitreous.

Fundus examination of the right eye was notable for mild vitritis, vascular attenuation, and peripheral artery occlusion, as well as scattered intraretinal and perivascular hemorrhages.

Fluorescein angiography revealed delayed retinal filling, peripheral vascular occlusion, extended areas of non-perfusion, and scattered areas of perivascular staining. The optical coherence tomography examination was unremarkable.

A 6 × 6 zone was acquired using optical coherence tomography angiography demonstrating the junction between perfusion and non-perfusion areas showing the choroidal vasculature intact.

Diagnosis of hemorrhagic occlusive retinal vasculitis (HORV) was made.

DISEASE

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 successful 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
A predilection for venules and peripheral involvement

Test your knowledge 10 questions from this article

Diagnostic procedures

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 the inner retina, and cystoid macular edema (rare).
B-scan ultrasonography is needed in cases of media haze due to vitreous hemorrhage.

MANAGEMENT

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 the second eye

The recommendations for Hemorrhagic Occlusive Retinal Vasculitis (HORV) are as follows:

Considerations for intraocular vancomycin use

Because Hemorrhagic Occlusive Retinal Vasculitis (HORV) seems 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.

Recommendations for the 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 pan-retinal photocoagulation.

REFERENCES

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.

Test yourself

A few questions straight from this article.

1 / 10 0 correct

Hemorrhagic occlusive retinal vasculitis (HORV) is a rare complication of cataract surgery using which intraocular agent?
HORV is described as a very rare but potentially devastating complication of cataract surgery in which intraocular vancomycin is used.
Over what postoperative interval does hemorrhagic occlusive retinal vasculitis typically present?
Patients may present from 1 to 21 days postoperatively with a mean of 8 days; the original series described presentation 1 to 14 days after surgery.
Which combination of findings is characteristic of hemorrhagic occlusive retinal vasculitis?
HORV has a delayed onset and is associated with retinal hemorrhages, vascular nonperfusion and venous sheathing.
Which feature helps distinguish hemorrhagic occlusive retinal vasculitis from postoperative endophthalmitis?
HORV shows only mild anterior chamber and vitreous inflammation, unlike the marked reaction of endophthalmitis; the case described a reaction not suggestive of endophthalmitis.
Where are the retinal hemorrhages of hemorrhagic occlusive retinal vasculitis characteristically located?
Characteristic features include sectoral retinal hemorrhages in areas of ischemia, with a predilection for venules and peripheral involvement.
What does fundus fluorescein angiography typically demonstrate in hemorrhagic occlusive retinal vasculitis?
Fundus fluorescein angiography in HORV shows severe capillary nonperfusion; the reported case also had delayed retinal filling and perivascular staining.
Which optical coherence tomography changes may be seen in hemorrhagic occlusive retinal vasculitis?
OCT may show inner retinal hyperreflectivity and increased inner retinal thickness, with cystoid macular edema being rare.
Why should a dilated retinal examination be performed on the first eye before sequential cataract surgery?
Besides its delayed onset, HORV may cause no symptoms in the first eye, so dilated retinal examination may be the only way to detect it before operating on the second eye.
Which alternatives to vancomycin are suggested for intracameral prophylaxis in cataract surgery?
Surgeons wanting an alternative to vancomycin for intracameral prophylaxis may consider cefuroxime or moxifloxacin.
Which treatments are recommended to prevent neovascular glaucoma in hemorrhagic occlusive retinal vasculitis?
Alongside aggressive systemic and topical corticosteroids, early anti-VEGF injection and early panretinal photocoagulation may prevent neovascular glaucoma; intravitreal vancomycin should be avoided.