antibiotic formulation into the eye to reduce the risk of endophthalmi-
tis and to largely eliminate the need for post-op eye drops, says Dr.
Goldberg.
Surgeons also use intraoperative intraocular vancomycin to reduce
the risk of post-op endophthalmitis, but the practice is not without
controversy and is being reevaluated among eye surgeons and policy-
makers. In October, the FDA warned against the use of intraocular
vancomycin during cataract surgery to prevent endophthalmitis after
reports surfaced that hemorrhagic occlusive retinal vasculitis (HORV)
— characterized by sudden decreased vision, intraocular inflammation
and intraretinal hemorrhage — developed in patients following injec-
tions of a compounded triamcinolone, moxifloxacin and vancomycin
formulation at the end of otherwise uncomplicated cataract surgeries.
There is no FDA-approved vancomycin formulation for intraocular
injection. The FDA, which is unaware of any adequately controlled
studies demonstrating the safety and efficacy of intraocular van-
comycin in preventing endophthalmitis, recommends against the pro-
phylactic use of the antibiotic alone or in a compounded drug during
cataract surgery because of the risk of HORV.
"We're still trying to get a handle on the scope of the problem," says
Dr. Goldberg. "Vancomycin makes an already low rate of infection
even lower, but the therapy introduces its own risk. It's a balancing
act, and at some point, the injections don't provide additional benefit
in relation to the risk it introduces."
Dr. Shorstein points out that some cataract surgeons use an intra-
cameral lidocaine-phenylephrine combination for mydriasis in
patients with small pupils or in patients who've had exposure to tam-
sulosin. "There are no FDA-approved injectable products for those
indications, so injectable versions must be obtained from a com-
pounding pharmacy," he adds.
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