Can Vancomycin Cause Eye Problems? Understanding the Risks by Administration Route

October 7, 2025 •

4 min read

While vancomycin is a powerful antibiotic used to treat serious infections, a specific mode of administration—intraocular injection—is associated with a rare but potentially devastating condition called Hemorrhagic Occlusive Retinal Vasculitis (HORV). This raises a critical question: can vancomycin cause eye problems?

Quick Summary

Vancomycin can cause eye problems, from temporary irritation with eye drops and rare systemic effects to the potentially blinding hemorrhagic occlusive retinal vasculitis (HORV) associated with intraocular injections.

Key Points

Intraocular Injections Carry a Major Risk: Prophylactic vancomycin injections into the eye during cataract surgery can cause Hemorrhagic Occlusive Retinal Vasculitis (HORV), a rare but potentially blinding condition.
Topical Eye Drops Cause Local Irritation: Compounded vancomycin eye drops for severe eye infections can cause temporary stinging, burning, or irritation, and rarely an allergic reaction.
Systemic Vancomycin Has Limited Direct Ocular Effects: When taken orally or intravenously, vancomycin does not readily cross the blood-retinal barrier, though indirect ocular issues can occur from severe systemic reactions.
Rare Photophobia Linked to Oral Use: A case report described chronic photophobia (light sensitivity) following oral vancomycin therapy, suggesting a rare systemic side effect.
FDA Has Issued Warnings: The FDA has issued warnings and recommendations against the prophylactic use of intraocular vancomycin due to the risk of HORV.
Symptoms of HORV are Distinct: HORV is characterized by a delayed, painless decrease in vision, intraocular inflammation, and retinal hemorrhages, often weeks after surgery.

Vancomycin is a critical antibiotic for treating a range of serious infections, particularly those caused by drug-resistant bacteria like MRSA. While systemic (oral or intravenous) administration is generally well-tolerated concerning ocular health, the risks vary significantly depending on how the drug is administered. The most severe eye complications are linked to intraocular injections, a practice that has been scrutinized by medical authorities.

Ocular Complications from Intraocular Injections

Intraocular injection involves administering medication directly into the eye. This route has been used by some ophthalmologists to prevent infection during cataract surgery. However, the FDA and medical societies have warned against its use due to the risk of a severe complication known as Hemorrhagic Occlusive Retinal Vasculitis (HORV).

Hemorrhagic Occlusive Retinal Vasculitis (HORV): HORV is a delayed-onset, inflammatory condition that causes severe damage to the retinal blood vessels. It typically presents with a sudden, painless decrease in vision one to three weeks after surgery and can lead to significant vision loss or blindness. A task force identified numerous cases linked to intraocular vancomycin, with higher doses increasing the risk. The condition is thought to be a hypersensitivity reaction to the vancomycin.
Associated Symptoms:
- Sudden, painless reduced vision
- Intraocular inflammation
- Retinal hemorrhages (bleeding)
- Retinal vasculitis (inflammation of retinal vessels)
- Vascular occlusion (blockage of vessels)
- Neovascular glaucoma (abnormal blood vessel growth)

Eye Problems from Topical Vancomycin (Eye Drops)

Vancomycin eye drops are compounded for treating severe bacterial eye infections like keratitis and endophthalmitis. Unlike intraocular injections, the risks associated with topical application are generally localized and less severe.

Common Side Effects: Fortified vancomycin eye drops can cause temporary stinging, burning, or irritation upon application. Some patients may also experience temporary blurred vision. These symptoms usually resolve quickly.
Allergic Reactions: Rare cases of allergic reactions to topical vancomycin have been reported, presenting as ocular hypersensitivity with symptoms like conjunctival redness and eyelid edema. Discontinuation of the drops typically resolves the allergy.
In Vitro Cytotoxicity: Lab studies show that while fortified vancomycin eye drops can have an initial cytotoxic effect on corneal cells, this effect may be reversible over time. The concentration and duration of exposure are key factors.

Systemic Vancomycin and Ocular Side Effects

Systemic vancomycin, administered intravenously or orally, is not known to cross the blood-retinal barrier effectively in healthy eyes, limiting its direct toxicity to the retina. However, indirect ocular issues can arise.

Systemic Allergic Reactions: Severe systemic allergic reactions, such as Stevens-Johnson syndrome (SJS) or Toxic Epidermal Necrolysis (TEN), are very rare but life-threatening side effects of vancomycin. These reactions can cause severe, widespread skin blistering and irritation of the eyes.
Chronic Photophobia: A case report documented chronic photophobia (sensitivity to light) in a patient following treatment with oral vancomycin, suggesting a rare adverse effect potentially linked to systemic absorption.
Post-Cataract Surgery Complications: One retrospective study linked systemic vancomycin use within a year of surgery to higher rates of certain post-cataract eye complications, including retinal edema, macular puckering, and ischemic optic neuropathy. It is important to note that this was an observational study, and further research is needed to confirm the association.

How Ocular Risks Compare by Administration Route


Feature	Intraocular Injection	Topical Application (Eye Drops)	Systemic Administration (IV/Oral)
Associated Ocular Risk	High, for HORV	Low, for localized irritation	Very Low, for direct ocular effects
Primary Condition	Hemorrhagic Occlusive Retinal Vasculitis (HORV)	Temporary stinging, burning, irritation	Indirect effects from severe allergic reactions
Severity	Potentially blinding	Mild and temporary	Life-threatening (SJS/TEN) or rare/mild (photophobia)
Mechanism	Delayed hypersensitivity reaction	Direct surface irritation or local allergy	Indirect effect from systemic illness or rare absorption
Onset	Delayed (1-3 weeks post-injection)	Immediate	Can vary, often with other systemic symptoms
Medical Stance	Prophylactic use not recommended by FDA	Acceptable for severe ocular infections	Standard of care for systemic infections

Precautions and Patient Awareness

Given the varied risks, patient awareness is crucial, especially for those undergoing eye procedures or using topical treatments. Healthcare providers must carefully weigh the benefits and risks of vancomycin based on the intended use. For instance, the use of intraocular vancomycin for endophthalmitis prophylaxis is no longer widely recommended due to the risk of HORV.

This decision-making process involves considering the specific type of infection, the patient's medical history, and the potential for rare but serious side effects. For patients receiving topical vancomycin, monitoring for increasing irritation or allergic signs is important. Any sudden or persistent vision changes should be reported to a healthcare provider immediately, regardless of the vancomycin administration route. The FDA actively encourages reporting adverse events to its MedWatch program to improve drug safety.

Conclusion

While systemic vancomycin poses a very low risk of direct ocular complications, the answer to "Can vancomycin cause eye problems?" is a definitive yes, particularly with intraocular injections. The most severe risk, Hemorrhagic Occlusive Retinal Vasculitis (HORV), is a rare but devastating condition specifically associated with intraocular vancomycin use. For topical drops and systemic administration, the risks are far milder or indirect, though rare allergic or systemic reactions can have ocular symptoms. By understanding the distinct risks associated with each administration method, patients and clinicians can make informed decisions and remain vigilant for any visual side effects. The medical community and regulatory bodies have acted to highlight and mitigate the risk of HORV, changing standard practice for prophylactic use in eye surgery.

FDA warns of HORV risk with compounded vancomycin

Frequently Asked Questions

HORV is a rare but severe eye condition causing inflammation and blockage of retinal blood vessels, leading to vision loss. It has been specifically linked to intraocular vancomycin injections during cataract surgery.

Compounded vancomycin eye drops can cause temporary stinging, burning, or blurred vision and, rarely, an allergic reaction. These effects are generally mild and localized, unlike the severe risks associated with intraocular injections.

Direct ocular toxicity from systemic vancomycin is very low, as the drug does not cross the blood-retinal barrier well. However, severe systemic allergic reactions like Stevens-Johnson syndrome can cause red, irritated eyes, and a rare case of chronic photophobia has been reported with oral use.

Some ophthalmologists have used intraocular vancomycin as a preventive measure against infection (endophthalmitis) during cataract surgery. However, this practice is not FDA-approved and is generally not recommended due to the risk of HORV.

Any persistent or sudden changes in eyesight should be reported to a healthcare provider or eye specialist for evaluation, regardless of the vancomycin administration route.

Ischemic optic neuropathy has been associated with vancomycin use within a year of cataract surgery in one retrospective study, but this was a rare finding. Other antibiotics, like Linezolid, are more frequently linked to toxic optic neuropathy.

Yes, in 2017, the FDA issued a warning about the risk of HORV with intraocular vancomycin use and added a severe vision loss warning to the labels of injectable vancomycin.