Haemorrhagic Occlusive Retinal Vasculitis Following Cataract Surgery Without Intraocular Vancomycin

This paper reports a rare case of haemorrhagic occlusive retinal vasculitis (HORV) following cataract surgery in the absence of intraocular vancomycin, raising important considerations about alternative aetiologies and perioperative management. A 79-year-old male patient with a background of type 2 diabetes, benign prostatic hyperplasia and asthma experienced recurrent hypersensitivity reactions to topical mydriatics during preoperative assessments for right eye cataract surgery in the private sector. Surgery was ultimately performed without topical mydriatics; full mydriasis was achieved with the use of intracameral mydriatic agents and iris hooks. No intraocular vancomycin was administered. Postoperative care included standard antibiotic-steroid eye drops. Three days postoperatively, the patient presented with sudden, painless vision loss. Examination revealed extensive retinal haemorrhages, vasculitis, and macular ischaemia. Imaging confirmed widespread retinal vascular damage. Infectious and autoimmune screens were negative. A diagnosis of HORV was made, and the patient was treated with intravenous methylprednisolone, topical corticosteroids, and later sub-tenon triamcinolone. Partial visual improvement was observed. This case highlights the possibility of HORV in the absence of vancomycin, suggesting that other immune-mediated or hypersensitivity pathways, in response to different triggers, may contribute to its pathogenesis.