This 35YO male underwent uneventful cataract surgery in his left eye at an outside facility about two weeks earlier. On postoperative day 4-5, he developed mild blurring and floaters, raising suspicion for early postoperative endophthalmitis. He underwent vitreous tap with intravitreal vancomycin and ceftazidime. Although he noticed initial mild symptomatic improvement, over the next 5-7 days, he experienced progressive and profound vision loss. Vision in our office was light perception. The anterior segment was quiet.
Fundus photography shows a circular band of midperipheral fibrosed retinal neovascularization encircling the posterior pole. The pericentral macula shows inner retinal white ischemia, and there are scattered retinal hemorrhages. Fluorescein angiography shows dramatic capillary loss encircling the midperiphery and temporal macula. The foveal avascular zone is irregularly enlarged. Panretinal photocoagulation (PRP) was advised, but she was lost to follow-up immediately.
Learning Points:
Hemorrhagic occlusive retinal vasculitis (HORV) is a rare but devastating complication strongly associated with intraocular vancomycin exposure, typically presenting 1-21 days after cataract surgery or intravitreal injection with delayed-onset painless vision loss (Witkin et al, Ophthalmology 2017;14:583-595). It is characterized by sectoral ischemia with retinal hemorrhages, mild anterior chamber and vitreous inflammation, often with a deceptively unremarkable postoperative day 1 examination. The findings are likely due to a delayed hypersensitivity reaction rather than direct toxicity (Todorich et al, AJO 2018;188:131-140).
The visual prognosis is poor, with approximately 61% of eyes achieving <20/200 vision and 22% progressing to no light perception. Neovascular glaucoma develops in approximately 56% of cases due to extensive retinal ischemia. Management includes early systemic and/or intravitreal corticosteroids, and subsequent PRP and anti-VEGF therapy.
