Intravitreal Vancomycin:  Retinal Toxicity, Clearance, and Interaction With Gentamicin

• Some of the gram-positive isolates from exogenous bacterial endophthalmitis cases treated at our institution have been found to be resistant to either cefazolin sodium, gentamicin sulfate, or both. However, all of these isolates have been sensitive to vancomycin. These findings prompted us to reevaluate the retinal toxicity and clearance of intravitreal vancomycin in pigmented rabbits. Doses up to 2 mg were found to be nontoxic in phakic and aphakic-vitrectomized eyes. Clearance was determined in phakic and aphakic-vitrectomized rabbit eyes with or without intact lens capsules. The antibiotic was cleared most slowly in phakic eyes. Aphakic-vitrectomized eyes without an intact lens capsule cleared antibiotic most rapidly, while aphakic-vitrectomized eyes with intact capsules exhibited an intermediate clearance rate. In addition, the interaction between vancomycin and gentamicin on gram-positive endophthalmitis isolates was found to be additive or synergistic depending on the bacterial species. Based on these data, we recommend the combination of vancomycin and an aminoglycoside as the initial antibiotic therapy for exogenous bacterial endophthalmitis.