- Email: [email protected]
Safety and efficacy of intravitreal injection of steroid and antibiotics in the setting of cataract surgery and trabecular microbypass stent
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ARTICLE
Safety and efficacy of intravitreal injection of steroid and antibiotics in the setting of cataract surgery and trabecular microbypass stent Trevor Kindle, MD, Tanner Ferguson, BS, Mitch Ibach, OD, Michael Greenwood, MD, Justin Schweitzer, OD, Russell Swan, MD, Ramu G. Sudhagoni, PhD, John P. Berdahl, MD
Purpose: To evaluate the safety and efficacy of intravitreal administration of a steroid and antibiotics during cataract surgery compared with the typical postoperative topical regimen in preventing postoperative inflammation, pain, cystoid macular edema (CME), and endophthalmitis. Setting: Private practice, Sioux Falls, South Dakota, USA. Design: Retrospective case series. Methods: The study group included eyes that had an intravitreal injection of triamcinolone–moxifloxacin–vancomycin at the time of cataract surgery with concomitant trabecular microbypass stent insertion. The control eyes had the same procedure but were prescribed topical antibiotics, steroids, and nonsteroidal antiinflammatory drugs postoperatively. Data were recorded preoperatively and 1 day, 1 week, 1 month, and 3 months postoperatively. Primary outcomes included the number of glaucoma medications,
C
ataract surgery is 1 of the most commonly performed surgeries worldwide.1 With the aging population, this number will only continue to rise.2 As a consequence, new tools and techniques are frequently being introduced in efforts to obtain better outcomes and improve the safety and efficacy of the procedure. Although complications are not particularly common, the complications that can result are serious and have sight-threatening potential.3 Ophthalmologists use chemoprophylaxis to prevent potential complications. Cystoid macular edema (CME) is the most common cause of decreased vision after cataract
intraocular pressure (IOP), and IOP spikes of at least 15 mm Hg from baseline.
Results: There were 234 eyes in the study group and 249 eyes in the control group. The mean reduction in glaucoma medications was 0.24 drops in the study group and 0.80 drops in the control group 3 months postoperatively, whereas the mean IOP reduction was 2.59 mm Hg in the study group and 3.63 mm Hg in the control group. Pressure spikes were detected at 54 (5.7%) of 936 postoperative visits in the study group and at 37 (3.7%) of 996 visits in the control group. There were no cases of severe inflammation, CME, infection, or retinal detachments.
Conclusions: Both groups had similar postoperative pressure reductions and incidence of IOP spikes. The results indicate that intravitreal injections of a steroid and antibiotics might be a safe option for glaucomatous eyes having cataract surgery with trabecular microbypass stent insertion. J Cataract Refract Surg 2018; 44:56–62 Q 2018 ASCRS and ESCRS
surgery.4 Combinations of steroids and nonsteroidal antiinflammatory drugs (NSAIDs) have been shown to be appropriate prophylactic and definitive treatment regimens for CME.5 Inflammation and pain are also potential complications, and these can be prevented or treated similarly using steroids and NSAIDs.6,7 Endophthalmitis is likely the most feared complication of cataract surgery because of its sightthreatening potential. Although the overall incidence is less than 0.1%, clinicians remain motivated to minimize its occurrence.8 Povidone–iodine surgical preparations and antibiotics (perioperative and postoperative) are typically used as preventative measures against infection.
Submitted: April 28, 2017 | Final revision submitted: September 9, 2017 | Accepted: October 14, 2017 From the University of South Dakota Sanford School of Medicine (Kindle, Ferguson), the University of South Dakota School of Health Sciences (Sudhagoni), and Vance Thompson Vision (Ibach, Schweitzer, Berdahl), Sioux Falls, South Dakota, and Vance Thompson Vision (Greenwood), Fargo, North Dakota, and Vance Thompson Vision (Swan), Bozeman, Montana, USA. Presented as a poster at the ASCRS Symposium on Cataract, IOL and Refractive Surgery, New Orleans, Louisiana, USA, May 2016 Corresponding author: Trevor Kindle, MD, Vance Thompson Vision, 3101 West 57th Street, Sioux Falls, South Dakota 57108, USA. E-mail: [email protected]. Q 2018 ASCRS and ESCRS Published by Elsevier Inc.
0886-3350/$ - see frontmatter https://doi.org/10.1016/j.jcrs.2017.10.040
SAFETY OF INTRAVITREAL INJECTION OF STEROID AND ANTIBIOTICS
Although the actual drug classes used to prevent CME, inflammation, pain, and endophthalmitis after cataract surgery are generally agreed upon, the practice patterns for administration of these medications vary widely. In the United States, topical administration remains the most common practice. Topical NSAIDs lower the risk for CME and help treat postoperative pain and/or inflammation.7 Similarly, topical steroids are effective at reducing postoperative pain and inflammation.9 In the U.S., the perioperative use of topical antibiotics remains the most common method of endophthalmitis prevention.10 For various reasons, the use of topical medications, in particular antibiotics, has been debated in recent years. Surgeons have questioned the efficacy of topical antibiotics as a means of endophthalmitis prophylaxis, whereas others have suggested that simply using perioperative povidone–iodine alone is equally effective at preventing endophthalmitis.11,12 Furthermore, eyedrops can irritate the cornea and regimens are often complicated and burdensome to patients, which contributes to poor compliance.13–15 In addition, the drops are typically expensive, and 1 study that evaluated patient compliance in cataract surgery14 found that patients only used one half of the prescribed number of drops as part of their regimen. Ultimately, these challenges and data suggest that compliance is a legitimate concern and can contribute to poor outcomes and complications for patients. Thus, surgeons have been evaluating and pursuing drugdelivery alternatives to topical medications. In European countries such as Sweden, intracameral antibiotics are used almost exclusively and have been shown to be efficacious.16,17 Similarly, the use of intracameral triamcinolone to reduce postoperative inflammation has been studied.15 Although it is encouraging that surgeons have been able to safely and effectively use medications inside the eye, barriers remain that might slow adoption. In the U.S., intracameral antibiotics are not available in a compounded form.18 Other concerns include reports of delayed adverse sequelae and lack of an approved antibiotic in some markets. Recently, there has been an increased interest in the use of intraocular medications after cataract surgery. Much of this interest was stimulated by the results of the European Society of Cataract and Refractive Surgeons clinical trial, which showed the use of intracameral cefuroxime significantly reduced the risk for endophthalmitis.19 Another group studied the use of a regulated and compounded combination of triamcinolone, moxifloxacin, and vancomycin, and found this transzonular intravitreal injection was effective at preventing infection and inflammation.20 Similarly, a study performed at a private practice group evaluating intravitreal triamcinolone–moxifloxacin had comparable results.A Although steroid response resulting in increased intraocular pressure (IOP) is a concern, in particular in glaucoma patients, studies have shown intravitreal triamcinolone to be generally well tolerated.21,22 There are numerous approaches for administering prophylactic medications, including intracameral, pars plana, and transzonular. The transzonular technique has been considered more challenging and disruption of the anterior hyaloid
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membrane is a concern. Because ophthalmologists around the world use the pars plana approach every day in clinics to treat various retinal conditions, we feel it is a more suitable approach. In this study, we evaluated the safety and efficacy of an intravitreal injection of a steroid (triamcinolone) and antibiotics (moxifloxacin, vancomycin) at the time of cataract surgery using a pars plana approach of administration. PATIENTS AND METHODS In addition to complying with the U.S. Health Insurance Portability and Accountability Act of 1996, this project was granted approval from the University of South Dakota Institutional Review Board. This was a single-center retrospective chart review of eyes from January 2015 to December 2015 that had concurrent cataract surgery and implantation of a trabecular microbypass stent in a private practice setting. All patients had been previously diagnosed with primary open-angle glaucoma. The patients had a preoperative assessment to establish a baseline. Demographic information (age, sex), corrected distance visual acuity (CDVA), glaucoma medications, and IOP were recorded. To assess outcomes, data were collected at postoperative visits from 1 day, 1 week, 1 month, and 3 months. At each visit, the data collected included IOP, number and type of medications, and CDVA. The primary outcome measures in the study included IOP by Goldmann applanation tonometry and the number of glaucoma medications. To evaluate safety, the incidence of IOP spikes was also recorded, which was defined as an increase of at least 15 mm Hg from baseline IOP. The patients were divided into 2 groups. The study group included patients who had a pars plana intravitreal injection of triamcinolone, moxifloxacin, and vancomycin at the time of surgery and a topical NSAID drop daily for 4 weeks after the procedure. The study group is also referred to as the dropless or injection group throughout this paper. The intravitreal injection, which is available in a compounded form, was a 0.2 mL injection of the combination of 15 mg/1 mg/ 10 mg/mL concentration of triamcinolone, moxifloxacin, and vancomycin, respectively. Therefore, the eye received 3 mg of triamcinolone, 0.2 mg of moxifloxacin, and 2 mg of vancomycin with each injection. Of note, in January of 2016, the center transitioned to a triamcinolone–moxifloxacin only injection because of concerns regarding the potential association between vancomycin and hemorrhagic occlusive retinal vasculitis that has been described previously. 23 However, only eyes treated with triamcinolone–moxifloxacin–vancomycin were included in the study population. The control group comprised eyes that received a standard topical regimen postoperatively. In this cohort, patients used a postoperative topical medication regimen consisting of an antibiotic (moxifloxacin 0.05% 4 times a day for 1 week), an NSAID (bromfenac 0.07% or nepafenac 0.3% once daily for 4 weeks), and a steroid (difluprednate 0.05% or prednisolone acetate 1.0% tapered over 4 weeks). For statistical analysis, a 2 independent-sample t test procedure was used to compare the mean IOP change between groups. A Wilcoxon Mann-Whitney test was used to compare the number of medications used between the 2 groups. A chi-square test was used to test sex dependency between the groups. The Fisher exact test was applied to test the difference between 2 population proportions. The significance level was set at 5%. All data analyses were performed using R software.B
RESULTS Of the 483 eyes in the study, 234 eyes were in the study group, which received the intravitreal injection of a steroid and antibiotics at the time of surgery, and the remaining 249 eyes were in the control group, which used all topical Volume 44 Issue 1 January 2018
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Table 1. Preoperative demographics and baseline measurements. Parameter Mean age (y) Female Sex, n (%) Mean preop IOP (mm Hg) Mean preop glaucoma meds (n) Mean preop CDVA (logMAR)
Intravitreal Injection*
Traditional Drops†
P Value
69.8 G 8.7 149 (64) 17.78 G 5.29 0.84 G 0.91 0.28 G 0.20
74.0 G 8.0 152 (61) 19.00 G 6.04 1.19 G 1.00 0.28 G 0.22
!.001z .62 .018z .024z .52
CDVA Z corrected distance visual acuity; IOP Z intraocular pressure; logMAR Z logarithm of the minimum angle of resolution Means G SD *Study group † Control group z Statistically significant
medications. Table 1 shows the patient demographics and baseline information. Of note, there was a statistically significant difference in mean age, preoperative IOP, and preoperative glaucoma medications between the 2 groups. The study (dropless) group was younger, had lower preoperative IOP readings, and used fewer glaucoma medications at baseline than the control group. Figure 1 shows the mean IOP at each timepoint in both groups. The mean IOP increased in both groups 1 day postoperatively. Table 2 and Figure 2 show the incidence of IOP spikes in the 2 groups. The total or cumulative spikes at any postoperative visit were statistically similar between the 2 groups. In the dropless or injection group, 48 (20.5%) of 234 eyes experienced at least 1 IOP spike during the follow-up, whereas 33 (13.25%) of 249 eyes in the topical or control group experienced at least 1 IOP spike during the followup (P Z .038). Four of 234 eyes in the injection group and 3 of 249 eyes in the topical group had repeat pressure spikes (P Z .72). In the study group, there was a pressure spike of 15 mm Hg or higher at 54 (5.7%) of 936 postoperative visits. In the control group, there was a pressure spike of 15 mm Hg or
higher at 37 (3.7%) of 996 postoperative visits. There was no statistically significant difference in the rate of IOP spikes between the 2 groups (P Z .051). Table 3 shows the 3-month postoperative data. There was no statistically significant difference in IOP change from baseline between the 2 groups. However, the control group had a more robust reduction in medication use, which was statistically significant. Figure 3 shows the mean number of glaucoma medications at each visit. The difference in the mean reduction in medication use between each group was statistically significant (P ! .001). The CDVA assessments were similar between each group at all timepoints. DISCUSSION Numerous studies in the peer-reviewed literature have established the usefulness of intravitreal injections as chemoprophylaxis to reduce the likelihood of infection, inflammation, and postoperative discomfort after cataract surgery. This might be because of the poor compliance associated with topical medication regimens. There are multiple factors that contribute to poor compliance with
Figure 1. Mean IOP measurements (G1 SD) in the 2 groups after cataract surgery with trabecular microbypass stent placement (IOP Z intraocular pressure).
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Table 2. Incidence of IOP spikes by specific criteria. IOP Spike (%) Parameter 1 day postop 1 week postop 1 month postop 3 month postop Cumulative spikes for all visits Eyes with at least 1 spike Cumulative visit spikes minus 1 day Visits with repeat pressure spikes Eyes with multiple spikes
Injection/Dropless*
Topical/Drops†
P Value
13.25 4.70 3.42 1.28 5.66 20.51 3.13 0.71 (5/[234*3])z 1.71
10.44 3.21 0.80 0.40 3.71 13.25 1.47 0.54 (4/[249*3])x 1.20
.40 .49 .056 .36 .051 .038 .036 .75 .72
IOP Z intraocular pressure *Study group † Control group z Five postop visits at which an eye that previously had a pressure spike experienced a repeat pressure spike; 234*3 refers to the total number of postop visits after the 1 d visit (234 eyes 3 for 1 wk, 1 mo, 3 mo visits) x Four postop visits at which an eye that previously had a pressure spike experienced a repeat pressure spike; 249*3 refers to the total number of postop visits after the 1 d visit (249 eyes 3 for 1 wk, 1 mo, 3 mo visits)
topical regimens, including complicated schedules, expensive costs, difficulty with administration, and irritation from the agents.4,14,15 Recently, companies have started to combine multiple therapies into a single drop. For example, 1 available combination eyedrop is a topical formulation consisting of prednisolone acetate, moxifloxacin hydrochloride, and ketorolac tromethamine (Pred–Moxi–Ketor). Although combination drops simplify regimens, patients are still required to administer drops into their eye numerous times a day. Overall, the results of this retrospective chart review of 483 eyes are encouraging. The results showed there was IOP reduction in both groups. At 3 months, the mean pressure reduction was 2.59 mm Hg in the study group and 3.63 mm Hg in the control group. The difference in IOP reduction between both groups was similar and was
not statistically significant (P Z .062). The pressure reduction observed in both groups in this study is consistent with data in previous studies that evaluated the safety and efficacy of the combined procedure.24–27 Furthermore, no eyes required further surgical intervention within the first 3 months to decrease an elevated IOP after surgery. Regarding medication, both groups achieved a mean reduction in medication use 3 months after surgery; however, the control group had a more robust decrease in medication use with 0.8 fewer medications than baseline (P ! .001). The more significant decrease in medication use observed in the control group might be a result of the injected triamcinolone in the vitreous space remaining in the eye much longer than the types of topical steroids administered over 1 month. Previous studies found that
Figure 2. Percentage of eyes in the 2 groups with an IOP spike of at least 15 mm Hg from baseline (IOP Z intraocular pressure).
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Table 3. Three-month postoperative data. Mean ± SD Parameter Reduction in IOP (mm Hg) Reduction in medications (n) CDVA (logMAR)
Injection/Dropless*
Topical/Drops†
P Value
2.59 G 5.89 0.24 G 0.94 0.13 G 0.23
3.63 G 6.38 0.80 G 0.91 0.12 G 0.25
.062 !.001z .65
CDVA Z corrected distance visual acuity; IOP Z intraocular pressure; logMAR Z logarithm of the minimum angle of resolution *Study group † Control group z Statistically significant
clinically significant amounts of triamcinolone can remain for approximately 3 months after intravitreal injections, and furthermore, trace amounts of triamcinolone have been detected in animal models up to 8 months after intravitreal injection.28,29 In the case of the rabbit-eye model, the concentration of the triamcinolone does drop substantially in the first few months.29 This lingering concentration of steroid in the eye might contribute to increased IOP in patients who respond to steroids. However, in this study, both groups had similar reductions in IOP and both achieved reductions in glaucoma medications from baseline. The incidence of pressure spikes of 15 mm Hg or higher above baseline was a primary outcome of interest in this study. A statistically significant difference was not found between the 2 groups in the cumulative number of pressure spikes (P Z .051). Most of the pressure spikes occurred in the first 24 hours after surgery in both groups. These data suggest that despite the lingering steroid in the vitreous (discussed previously), the steroid effect on IOP does not lead to significant pressure increases above baseline days to months after surgery. This finding is consistent with a previous study that evaluated the use of a intracanalicular
depot of dexamethasone for slow release of a steroid that did not result in greater incidence of IOP spikes than those experienced by a group that had a standard topical regimen.30 The safety profiles of both groups were favorable. In the study group, there were no reported cases of inflammation, CME, or infection. No retinal detachments (RD) occurred during the 3-month postoperative period. These findings are consistent with previous literature evaluating the pars plana approach of intravitreal injections that found infection rates and RD rates were less than 1.0%.31 Furthermore, the use of topical povidone–iodine, which is already part of the cataract surgery preparation, has been shown to decrease postintravitreal injection endophthalmitis rates even more.32 In addition, the usefulness of intraocular antibiotics in preventing endophthalmitis has been shown previously. One study showed that intracameral cefuroxime had a 100% success rate in preventing postsurgical endophthalmitis.33 Another study34 found that intracameral moxifloxacin resulted in a statistically significant reduction in endophthalmitis rates compared with patients who received topical chemoprophylaxis. Last, another study could not find an
Figure 3. Mean number of glaucoma medications (G1 SD) used by patients in both groups after cataract surgery with trabecular microbypass stent placement.
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appreciable difference in the effectiveness of preventing postoperative endophthalmitis between intraocular moxifloxacin and cefuroxime, and both of these intracameral options were better than topical antibiotics in preventing infection.35 One can see the benefits associated with using intraocular antibiotics for chemoprophylaxis. Our study was not without limitations. It was an openlabel nonrandomized study. The use of the stent in both groups could have mitigated the effect of the steroid on pressure. At baseline, the 2 groups were statistically different in terms of age, IOP, and baseline glaucoma medications. This difference at baseline might contribute to challenges in comparing medication reduction between the 2 groups. However, it should be emphasized that the study group represented the final 234 eyes that had the triamcinolone–moxifloxacin–vancomycin intravitreal injection immediately before the site transitioned to an injection containing only triamcinolone and moxifloxacin. No additional inclusion or exclusion criteria were used in the study group to prevent selection bias and to mimic the clinical use of the intravitreal injection approach. From this study, there are numerous avenues for further evaluation. Future studies could focus on the safety and efficacy of the currently used injection of triamcinolone and moxifloxacin without vancomycin. Additional research could explore the rate of pressure spikes in nonglaucomatous eyes versus glaucomatous eyes using the intravitreal approach. Previously, subconjunctival, intracameral, and transzonule intravitreal triamcinolone injections have been shown to be generally well tolerated without significant pressures spikes when administered in conjunction with phacoemulsification only.20,36,37 There have also been reports of significant pressure elevations after intravitreal steroid injection; however, these occurred when treating macular edema and retinal neovascularization in nonglaucomatous eyes.38 Although the most critical aspect of intravitreal administration is reducing the risk for infection, pain, and other adverse events, patient experience is also an important consideration. For some patients, the highest out-ofpocket expense in the entire process are the drops after surgery. This present study did not use surveys and/or reviews to assess patient satisfaction with either regimen. However, a previous study39 found that patients prefer the intravitreal injection over the topical regimen. In addition, triamcinolone injections often cause visual disturbances (eg, floaters), and using a clear steroid solution such as dexamethasone might alleviate this problem. Future studies focusing on the patient experience between the 2 approaches would be beneficial. With no exclusion criteria, this study mimics the clinical use of the intravitreal approach for delivering medications after cataract surgery. The early results from this study suggest that the intravitreal approach of administering medications might be a safe and effective option for glaucomatous eyes having cataract surgery with concomitant trabecular microbypass stent insertion. Although further studies are
required to solidify its role for both glaucomatous and nonglaucomatous eyes, our study suggests clinicians might consider the pars plana intravitreal injection of steroid and antibiotic as an alternative to topical regimens after cataract surgery.
WHAT WAS KNOWN Patient compliance with eyedrop medications is not outstanding. Intracameral and intravitreal antibiotics have been shown to be better than topical antibiotics in preventing postoperative endophthalmitis.
WHAT THIS PAPER ADDS Pars plana intravitreal injection of a steroid and antibiotics with a topical NSAID seemed to be a safe and effective option for reducing postoperative pain, inflammation, CME, and endophthalmitis. The intravitreal injection of triamcinolone–moxifloxacin–vancomycin did not contribute to significant pressure increases after cataract surgery in glaucomatous eyes.
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13. Stringham JD, Flynn HW Jr, Schimel AM, Banta JT. Dropless cataract surgery: what are the potential downsides? [editorial] Am J Ophthalmol 2016; 164 (4):viii–x € u €ndag C, Diestelhorst M. Electronic compliance moni14. Hermann MM, Ust toring of topical treatment after ophthalmic surgery. Int Ophthalmol 2010; 30:385–390 vesque V. Evaluation of eyedrop adminis15. An JA, Kasner O, Samek DA, Le tration by inexperienced patients after cataract surgery. J Cataract Refract Surg 2014; 40:1857–1861 16. Chang DF, Braga-Mele R, Henderson BA, Mamalis N, Vasavada A, for the ASCRS Cataract Clinical Committee. Antibiotic prophylaxis of postoperative endophthalmitis after cataract surgery: results of the 2014 ASCRS member survey. J Cataract Refract Surg 2015; 41:1300–1305 €ell JL, Kodjikian L, Mencucci R, Nuijts RMMA, 17. Behndig A, Cochener B, Gu Pleyer U, Rosen P, Szaflik JP, Tassignon M-J. Endophthalmitis prophylaxis in cataract surgery: Overview of current practice patterns in 9 European countries. J Cataract Refract Surg 2013; 39:1421–1431. Available at: http://www.jcrsjournal.org/article/S0886-3350(13)00872-9/pdf. Accessed November 7, 2017 18. Schimel AM, Alfonso EC, Flynn HW Jr. Endophthalmitis prophylaxis for cataract surgery. Are intracameral antibiotics necessary? [viewpoint] AMA Ophthalmol 2014; 132:1269–1270 19. Barry P, Seal DV, Gettinby G, Lees F, Peterson M, Revie CW, for the ESCRS Endophthalmitis Study Group. ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery; preliminary report of principal results from a European multicenter study. J Cataract Refract Surg 2006; 32:407–410; erratum, 709 20. Tyson SL, Bailey R, Roman JS, Zhan T, Hark LA, Haller JA. Clinical outcomes after injection of a compounded pharmaceutical for prophylaxis after cataract surgery: a large-scale review. Curr Opin Ophthalmol 2017; 28:73–80. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5145248/pdf /cooph-28-73.pdf. Accessed November 7, 2017 21. Gillies MC, Simpson JM, Billson FA, Luo W, Penfold P, Chua W, Mitchell P, Zhu M, Hunyor ABL. Safety of an intravitreal injection of triamcinolone; results from a randomized clinical trial. Arch Ophthalmol 2004; 122:336– 440. Available at: http://archopht.jamanetwork.com/article.aspx?arti cleidZ416158. Accessed November 7, 2017 22. Baath J, Ells AL, Crichton A, Kherani A, Williams RG. Safety profile of intravitreal triamcinolone acetonide. J Ocul Pharmacol Ther 2007; 23:304– 310 23. Witkin AJ, Shah AR, Engstrom RE, Kron-Gray MM, Baumal CR, Johnson MW, Witkin DI, Leung J, Albini TA, Moshfeghi AA, Batlle IR, Sobrin L, Eliott D. Postoperative hemorrhagic occlusive retinal vasculitis; expanding the clinical spectrum and possible association with vancomycin. Ophthalmology 2015; 122:1438–1451 24. Brown RH, Gibson Z, Zhong Le, Lynch MG. Intraocular pressure reduction after cataract surgery with implantation of a trabecular microbypass device. J Cataract Refract Surg 2015; 41:1318–1319 25. Fea AM. Phacoemulsification versus phacoemulsification with microbypass stent implantation in primary open-angle glaucoma; randomized double-masked clinical trial. J Cataract Refract Surg 2010; 36:407–412 26. Craven ER, Katz LJ, Wells JM, Giamporcaro JE, for the iStent Study Group. Cataract surgery with trabecular micro-bypass stent implantation in patients with mild-to-moderate open-angle glaucoma and cataract: twoyear follow-up. J Cataract Refract Surgery 2012; 38:1339–1345 27. Samuelson TW, Katz LJ, Wells JM, Duh Y-J, Giamporcaro JE, for the US iStent Study Group. Randomized evaluation of the trabecular microbypass stent with phacoemulsification in patients with glaucoma and cataract. Ophthalmology 2011; 118:459–467 28. Beer PM, Bakri SJ, Singh RJ, Liu W, Peters GB III, Miller M. Intraocular concentration and pharmacokinetics of triamcinolone acetonide after a single intravitreal injection. Ophthalmology 2003; 110:681–686 29. Kamppeter BA, Cej A, Jonas JB. Intraocular concentration of triamcinolone acetonide after intravitreal injection in the rabbit eye. Ophthalmology 2008; 115:1372–1375 30. Walters T, Bafna S, Vold S, Wortz G, Harton P, Levenson J, Hovanesia J, Mah F, Gira J, Vroman D, Sampson R, Berdahl J, Elmer T, Noecker RJ. Efficacy and safety of sustained release dexamethasone for the treatment of
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ocular pain and inflammation after cataract surgery: results from two phase 3 studies. J Clin Exp Ophthalmol 2016; 7:572–582. Available at: https: //www.omicsonline.org/open-access/efficacy-and-safety-of-sustained-relea se-dexamethasone-for-the-treatment-of-ocular-pain-and-inflammation -after-cataract-surgery-re-2155-9570-1000572.pdf. Accessed November 7, 2017 Falavarjani KG, Nguyen QD. Adverse events and complications associated with intravitreal injection of anti-VEGF agents: a review of literature. Eye 2013; 27:787–794. Available at: https://www.ncbi.nlm.nih.gov/pmc /articles/PMC3709385/pdf/eye2013107a.pdf. Accessed November 7, 2017 Vaziri K, Schwartz SG, Kishor K, Flynn HW Jr. Endophthalmitis: state of the art. Clin Ophthalmol 2015; 9:95–108. Available at: http://www.ncbi.nlm.nih .gov/pmc/articles/PMC4293922/pdf/opth-9-095.pdf. Accessed November 7, 2017 Jabbarvand M, Hashemian H, Khodaparast M, Jouhari M, Tabatabaei A, Rezaei S. Endophthalmitis occurring after cataract surgery; outcomes of more than 480 000 cataract surgeries, epidemiologic features, and risk factors. Ophthalmology 2016; 123:295–301 Haripriya A, Chang DF, Namburar S, Smita A, Ravindran RD. Efficacy of intracameral moxifloxacin endophthalmitis prophylaxis at Aravind Eye Hospital. Ophthalmology 2016; 123:302–308 Herrinton LJ, Shorstein NH, Paschal JF, Liu L, Contreras R, Winthrop KL, Chang WJ, Melles RB, Fong DS. Comparative effectiveness of antibiotic prophylaxis in cataract surgery. Ophthalmology 2016; 123:287–294. Available at: http://www.aaojournal.org/article/S0161-6420(15)00895-7/pdf. Accessed November 7, 2017 Shorstein NH, Liu L, Waxman MD, Herrinton LJ. Comparative effectiveness of three prophylactic strategies to prevent clinical macular edema following phacoemulsification surgery. Ophthalmology 2015; 122:2450–2460 Karalezli A, Borazan M, Kucukerdonmez C, Akman A, Akova YA. Effect of intracameral triamcinolone acetonide on postoperative intraocular pressure after cataract surgery. Eye 2010; 24:619–623. Available at: http://www.na ture.com/eye/journal/v24/n4/pdf/eye2009182a.pdf. Accessed November 7, 2017 Fitzgerald JT, Saunders L, Ridge B, Whie AJR, Goldberg I, Clark B, Mills RAD, Craig JE. Severe intraocular pressure response to periocular or intravitreal steroid treatment in Australia and New Zealand: data from the Australian and New Zealand ophthalmic surveillance unit. Clin Exp Ophthalmol 2015; 43:234–238 Fisher BL, Potvin R. Transzonular vitreous injection vs a single drop compounded topical pharmaceutical regimen after cataract surgery. Clin Ophthalmol 2016; 10:1297–1303. Available at: https://www.ncbi.nlm.nih.gov/pmc /articles/PMC4957678/pdf/opth-10-1297.pdf. Accessed November 7, 2017
OTHER CITED MATERIAL A. Galloway MS, “Intravitreal Placement of Antibiotic/Steroid as Substitute for Postoperative Drops After Cataract Surgery,” presented at the ASCRS Symposium on Cataract, IOL and Refractive Surgery, Boston, Massachusetts, USA, April 2014. Abstract available at: https://ascrs.confex.com/ascrs /14am/webprogram/Paper8473.html. Accessed November 7, 2017 B. R Development Core Team. The R Project for Statistical Computing. Vienna, Austria, R Foundation for Statistical Computing. Available at: https://www.r -project.org/. Accessed November 7, 2017
Disclosures: Drs. Ibach, Schweitzer, and Berdahl are consultants to and speakers for Glaukos Corp. None of the other authors has a financial or proprietary interest in any material or method mentioned.
First author: Trevor Kindle, MD University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA
ARTICLE
Safety and efficacy of intravitreal injection of steroid and antibiotics in the setting of cataract surgery and trabecular microbypass stent Trevor Kindle, MD, Tanner Ferguson, BS, Mitch Ibach, OD, Michael Greenwood, MD, Justin Schweitzer, OD, Russell Swan, MD, Ramu G. Sudhagoni, PhD, John P. Berdahl, MD
Purpose: To evaluate the safety and efficacy of intravitreal administration of a steroid and antibiotics during cataract surgery compared with the typical postoperative topical regimen in preventing postoperative inflammation, pain, cystoid macular edema (CME), and endophthalmitis. Setting: Private practice, Sioux Falls, South Dakota, USA. Design: Retrospective case series. Methods: The study group included eyes that had an intravitreal injection of triamcinolone–moxifloxacin–vancomycin at the time of cataract surgery with concomitant trabecular microbypass stent insertion. The control eyes had the same procedure but were prescribed topical antibiotics, steroids, and nonsteroidal antiinflammatory drugs postoperatively. Data were recorded preoperatively and 1 day, 1 week, 1 month, and 3 months postoperatively. Primary outcomes included the number of glaucoma medications,
C
ataract surgery is 1 of the most commonly performed surgeries worldwide.1 With the aging population, this number will only continue to rise.2 As a consequence, new tools and techniques are frequently being introduced in efforts to obtain better outcomes and improve the safety and efficacy of the procedure. Although complications are not particularly common, the complications that can result are serious and have sight-threatening potential.3 Ophthalmologists use chemoprophylaxis to prevent potential complications. Cystoid macular edema (CME) is the most common cause of decreased vision after cataract
intraocular pressure (IOP), and IOP spikes of at least 15 mm Hg from baseline.
Results: There were 234 eyes in the study group and 249 eyes in the control group. The mean reduction in glaucoma medications was 0.24 drops in the study group and 0.80 drops in the control group 3 months postoperatively, whereas the mean IOP reduction was 2.59 mm Hg in the study group and 3.63 mm Hg in the control group. Pressure spikes were detected at 54 (5.7%) of 936 postoperative visits in the study group and at 37 (3.7%) of 996 visits in the control group. There were no cases of severe inflammation, CME, infection, or retinal detachments.
Conclusions: Both groups had similar postoperative pressure reductions and incidence of IOP spikes. The results indicate that intravitreal injections of a steroid and antibiotics might be a safe option for glaucomatous eyes having cataract surgery with trabecular microbypass stent insertion. J Cataract Refract Surg 2018; 44:56–62 Q 2018 ASCRS and ESCRS
surgery.4 Combinations of steroids and nonsteroidal antiinflammatory drugs (NSAIDs) have been shown to be appropriate prophylactic and definitive treatment regimens for CME.5 Inflammation and pain are also potential complications, and these can be prevented or treated similarly using steroids and NSAIDs.6,7 Endophthalmitis is likely the most feared complication of cataract surgery because of its sightthreatening potential. Although the overall incidence is less than 0.1%, clinicians remain motivated to minimize its occurrence.8 Povidone–iodine surgical preparations and antibiotics (perioperative and postoperative) are typically used as preventative measures against infection.
Submitted: April 28, 2017 | Final revision submitted: September 9, 2017 | Accepted: October 14, 2017 From the University of South Dakota Sanford School of Medicine (Kindle, Ferguson), the University of South Dakota School of Health Sciences (Sudhagoni), and Vance Thompson Vision (Ibach, Schweitzer, Berdahl), Sioux Falls, South Dakota, and Vance Thompson Vision (Greenwood), Fargo, North Dakota, and Vance Thompson Vision (Swan), Bozeman, Montana, USA. Presented as a poster at the ASCRS Symposium on Cataract, IOL and Refractive Surgery, New Orleans, Louisiana, USA, May 2016 Corresponding author: Trevor Kindle, MD, Vance Thompson Vision, 3101 West 57th Street, Sioux Falls, South Dakota 57108, USA. E-mail: [email protected]. Q 2018 ASCRS and ESCRS Published by Elsevier Inc.
0886-3350/$ - see frontmatter https://doi.org/10.1016/j.jcrs.2017.10.040
SAFETY OF INTRAVITREAL INJECTION OF STEROID AND ANTIBIOTICS
Although the actual drug classes used to prevent CME, inflammation, pain, and endophthalmitis after cataract surgery are generally agreed upon, the practice patterns for administration of these medications vary widely. In the United States, topical administration remains the most common practice. Topical NSAIDs lower the risk for CME and help treat postoperative pain and/or inflammation.7 Similarly, topical steroids are effective at reducing postoperative pain and inflammation.9 In the U.S., the perioperative use of topical antibiotics remains the most common method of endophthalmitis prevention.10 For various reasons, the use of topical medications, in particular antibiotics, has been debated in recent years. Surgeons have questioned the efficacy of topical antibiotics as a means of endophthalmitis prophylaxis, whereas others have suggested that simply using perioperative povidone–iodine alone is equally effective at preventing endophthalmitis.11,12 Furthermore, eyedrops can irritate the cornea and regimens are often complicated and burdensome to patients, which contributes to poor compliance.13–15 In addition, the drops are typically expensive, and 1 study that evaluated patient compliance in cataract surgery14 found that patients only used one half of the prescribed number of drops as part of their regimen. Ultimately, these challenges and data suggest that compliance is a legitimate concern and can contribute to poor outcomes and complications for patients. Thus, surgeons have been evaluating and pursuing drugdelivery alternatives to topical medications. In European countries such as Sweden, intracameral antibiotics are used almost exclusively and have been shown to be efficacious.16,17 Similarly, the use of intracameral triamcinolone to reduce postoperative inflammation has been studied.15 Although it is encouraging that surgeons have been able to safely and effectively use medications inside the eye, barriers remain that might slow adoption. In the U.S., intracameral antibiotics are not available in a compounded form.18 Other concerns include reports of delayed adverse sequelae and lack of an approved antibiotic in some markets. Recently, there has been an increased interest in the use of intraocular medications after cataract surgery. Much of this interest was stimulated by the results of the European Society of Cataract and Refractive Surgeons clinical trial, which showed the use of intracameral cefuroxime significantly reduced the risk for endophthalmitis.19 Another group studied the use of a regulated and compounded combination of triamcinolone, moxifloxacin, and vancomycin, and found this transzonular intravitreal injection was effective at preventing infection and inflammation.20 Similarly, a study performed at a private practice group evaluating intravitreal triamcinolone–moxifloxacin had comparable results.A Although steroid response resulting in increased intraocular pressure (IOP) is a concern, in particular in glaucoma patients, studies have shown intravitreal triamcinolone to be generally well tolerated.21,22 There are numerous approaches for administering prophylactic medications, including intracameral, pars plana, and transzonular. The transzonular technique has been considered more challenging and disruption of the anterior hyaloid
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membrane is a concern. Because ophthalmologists around the world use the pars plana approach every day in clinics to treat various retinal conditions, we feel it is a more suitable approach. In this study, we evaluated the safety and efficacy of an intravitreal injection of a steroid (triamcinolone) and antibiotics (moxifloxacin, vancomycin) at the time of cataract surgery using a pars plana approach of administration. PATIENTS AND METHODS In addition to complying with the U.S. Health Insurance Portability and Accountability Act of 1996, this project was granted approval from the University of South Dakota Institutional Review Board. This was a single-center retrospective chart review of eyes from January 2015 to December 2015 that had concurrent cataract surgery and implantation of a trabecular microbypass stent in a private practice setting. All patients had been previously diagnosed with primary open-angle glaucoma. The patients had a preoperative assessment to establish a baseline. Demographic information (age, sex), corrected distance visual acuity (CDVA), glaucoma medications, and IOP were recorded. To assess outcomes, data were collected at postoperative visits from 1 day, 1 week, 1 month, and 3 months. At each visit, the data collected included IOP, number and type of medications, and CDVA. The primary outcome measures in the study included IOP by Goldmann applanation tonometry and the number of glaucoma medications. To evaluate safety, the incidence of IOP spikes was also recorded, which was defined as an increase of at least 15 mm Hg from baseline IOP. The patients were divided into 2 groups. The study group included patients who had a pars plana intravitreal injection of triamcinolone, moxifloxacin, and vancomycin at the time of surgery and a topical NSAID drop daily for 4 weeks after the procedure. The study group is also referred to as the dropless or injection group throughout this paper. The intravitreal injection, which is available in a compounded form, was a 0.2 mL injection of the combination of 15 mg/1 mg/ 10 mg/mL concentration of triamcinolone, moxifloxacin, and vancomycin, respectively. Therefore, the eye received 3 mg of triamcinolone, 0.2 mg of moxifloxacin, and 2 mg of vancomycin with each injection. Of note, in January of 2016, the center transitioned to a triamcinolone–moxifloxacin only injection because of concerns regarding the potential association between vancomycin and hemorrhagic occlusive retinal vasculitis that has been described previously. 23 However, only eyes treated with triamcinolone–moxifloxacin–vancomycin were included in the study population. The control group comprised eyes that received a standard topical regimen postoperatively. In this cohort, patients used a postoperative topical medication regimen consisting of an antibiotic (moxifloxacin 0.05% 4 times a day for 1 week), an NSAID (bromfenac 0.07% or nepafenac 0.3% once daily for 4 weeks), and a steroid (difluprednate 0.05% or prednisolone acetate 1.0% tapered over 4 weeks). For statistical analysis, a 2 independent-sample t test procedure was used to compare the mean IOP change between groups. A Wilcoxon Mann-Whitney test was used to compare the number of medications used between the 2 groups. A chi-square test was used to test sex dependency between the groups. The Fisher exact test was applied to test the difference between 2 population proportions. The significance level was set at 5%. All data analyses were performed using R software.B
RESULTS Of the 483 eyes in the study, 234 eyes were in the study group, which received the intravitreal injection of a steroid and antibiotics at the time of surgery, and the remaining 249 eyes were in the control group, which used all topical Volume 44 Issue 1 January 2018
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Table 1. Preoperative demographics and baseline measurements. Parameter Mean age (y) Female Sex, n (%) Mean preop IOP (mm Hg) Mean preop glaucoma meds (n) Mean preop CDVA (logMAR)
Intravitreal Injection*
Traditional Drops†
P Value
69.8 G 8.7 149 (64) 17.78 G 5.29 0.84 G 0.91 0.28 G 0.20
74.0 G 8.0 152 (61) 19.00 G 6.04 1.19 G 1.00 0.28 G 0.22
!.001z .62 .018z .024z .52
CDVA Z corrected distance visual acuity; IOP Z intraocular pressure; logMAR Z logarithm of the minimum angle of resolution Means G SD *Study group † Control group z Statistically significant
medications. Table 1 shows the patient demographics and baseline information. Of note, there was a statistically significant difference in mean age, preoperative IOP, and preoperative glaucoma medications between the 2 groups. The study (dropless) group was younger, had lower preoperative IOP readings, and used fewer glaucoma medications at baseline than the control group. Figure 1 shows the mean IOP at each timepoint in both groups. The mean IOP increased in both groups 1 day postoperatively. Table 2 and Figure 2 show the incidence of IOP spikes in the 2 groups. The total or cumulative spikes at any postoperative visit were statistically similar between the 2 groups. In the dropless or injection group, 48 (20.5%) of 234 eyes experienced at least 1 IOP spike during the follow-up, whereas 33 (13.25%) of 249 eyes in the topical or control group experienced at least 1 IOP spike during the followup (P Z .038). Four of 234 eyes in the injection group and 3 of 249 eyes in the topical group had repeat pressure spikes (P Z .72). In the study group, there was a pressure spike of 15 mm Hg or higher at 54 (5.7%) of 936 postoperative visits. In the control group, there was a pressure spike of 15 mm Hg or
higher at 37 (3.7%) of 996 postoperative visits. There was no statistically significant difference in the rate of IOP spikes between the 2 groups (P Z .051). Table 3 shows the 3-month postoperative data. There was no statistically significant difference in IOP change from baseline between the 2 groups. However, the control group had a more robust reduction in medication use, which was statistically significant. Figure 3 shows the mean number of glaucoma medications at each visit. The difference in the mean reduction in medication use between each group was statistically significant (P ! .001). The CDVA assessments were similar between each group at all timepoints. DISCUSSION Numerous studies in the peer-reviewed literature have established the usefulness of intravitreal injections as chemoprophylaxis to reduce the likelihood of infection, inflammation, and postoperative discomfort after cataract surgery. This might be because of the poor compliance associated with topical medication regimens. There are multiple factors that contribute to poor compliance with
Figure 1. Mean IOP measurements (G1 SD) in the 2 groups after cataract surgery with trabecular microbypass stent placement (IOP Z intraocular pressure).
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Table 2. Incidence of IOP spikes by specific criteria. IOP Spike (%) Parameter 1 day postop 1 week postop 1 month postop 3 month postop Cumulative spikes for all visits Eyes with at least 1 spike Cumulative visit spikes minus 1 day Visits with repeat pressure spikes Eyes with multiple spikes
Injection/Dropless*
Topical/Drops†
P Value
13.25 4.70 3.42 1.28 5.66 20.51 3.13 0.71 (5/[234*3])z 1.71
10.44 3.21 0.80 0.40 3.71 13.25 1.47 0.54 (4/[249*3])x 1.20
.40 .49 .056 .36 .051 .038 .036 .75 .72
IOP Z intraocular pressure *Study group † Control group z Five postop visits at which an eye that previously had a pressure spike experienced a repeat pressure spike; 234*3 refers to the total number of postop visits after the 1 d visit (234 eyes 3 for 1 wk, 1 mo, 3 mo visits) x Four postop visits at which an eye that previously had a pressure spike experienced a repeat pressure spike; 249*3 refers to the total number of postop visits after the 1 d visit (249 eyes 3 for 1 wk, 1 mo, 3 mo visits)
topical regimens, including complicated schedules, expensive costs, difficulty with administration, and irritation from the agents.4,14,15 Recently, companies have started to combine multiple therapies into a single drop. For example, 1 available combination eyedrop is a topical formulation consisting of prednisolone acetate, moxifloxacin hydrochloride, and ketorolac tromethamine (Pred–Moxi–Ketor). Although combination drops simplify regimens, patients are still required to administer drops into their eye numerous times a day. Overall, the results of this retrospective chart review of 483 eyes are encouraging. The results showed there was IOP reduction in both groups. At 3 months, the mean pressure reduction was 2.59 mm Hg in the study group and 3.63 mm Hg in the control group. The difference in IOP reduction between both groups was similar and was
not statistically significant (P Z .062). The pressure reduction observed in both groups in this study is consistent with data in previous studies that evaluated the safety and efficacy of the combined procedure.24–27 Furthermore, no eyes required further surgical intervention within the first 3 months to decrease an elevated IOP after surgery. Regarding medication, both groups achieved a mean reduction in medication use 3 months after surgery; however, the control group had a more robust decrease in medication use with 0.8 fewer medications than baseline (P ! .001). The more significant decrease in medication use observed in the control group might be a result of the injected triamcinolone in the vitreous space remaining in the eye much longer than the types of topical steroids administered over 1 month. Previous studies found that
Figure 2. Percentage of eyes in the 2 groups with an IOP spike of at least 15 mm Hg from baseline (IOP Z intraocular pressure).
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Table 3. Three-month postoperative data. Mean ± SD Parameter Reduction in IOP (mm Hg) Reduction in medications (n) CDVA (logMAR)
Injection/Dropless*
Topical/Drops†
P Value
2.59 G 5.89 0.24 G 0.94 0.13 G 0.23
3.63 G 6.38 0.80 G 0.91 0.12 G 0.25
.062 !.001z .65
CDVA Z corrected distance visual acuity; IOP Z intraocular pressure; logMAR Z logarithm of the minimum angle of resolution *Study group † Control group z Statistically significant
clinically significant amounts of triamcinolone can remain for approximately 3 months after intravitreal injections, and furthermore, trace amounts of triamcinolone have been detected in animal models up to 8 months after intravitreal injection.28,29 In the case of the rabbit-eye model, the concentration of the triamcinolone does drop substantially in the first few months.29 This lingering concentration of steroid in the eye might contribute to increased IOP in patients who respond to steroids. However, in this study, both groups had similar reductions in IOP and both achieved reductions in glaucoma medications from baseline. The incidence of pressure spikes of 15 mm Hg or higher above baseline was a primary outcome of interest in this study. A statistically significant difference was not found between the 2 groups in the cumulative number of pressure spikes (P Z .051). Most of the pressure spikes occurred in the first 24 hours after surgery in both groups. These data suggest that despite the lingering steroid in the vitreous (discussed previously), the steroid effect on IOP does not lead to significant pressure increases above baseline days to months after surgery. This finding is consistent with a previous study that evaluated the use of a intracanalicular
depot of dexamethasone for slow release of a steroid that did not result in greater incidence of IOP spikes than those experienced by a group that had a standard topical regimen.30 The safety profiles of both groups were favorable. In the study group, there were no reported cases of inflammation, CME, or infection. No retinal detachments (RD) occurred during the 3-month postoperative period. These findings are consistent with previous literature evaluating the pars plana approach of intravitreal injections that found infection rates and RD rates were less than 1.0%.31 Furthermore, the use of topical povidone–iodine, which is already part of the cataract surgery preparation, has been shown to decrease postintravitreal injection endophthalmitis rates even more.32 In addition, the usefulness of intraocular antibiotics in preventing endophthalmitis has been shown previously. One study showed that intracameral cefuroxime had a 100% success rate in preventing postsurgical endophthalmitis.33 Another study34 found that intracameral moxifloxacin resulted in a statistically significant reduction in endophthalmitis rates compared with patients who received topical chemoprophylaxis. Last, another study could not find an
Figure 3. Mean number of glaucoma medications (G1 SD) used by patients in both groups after cataract surgery with trabecular microbypass stent placement.
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appreciable difference in the effectiveness of preventing postoperative endophthalmitis between intraocular moxifloxacin and cefuroxime, and both of these intracameral options were better than topical antibiotics in preventing infection.35 One can see the benefits associated with using intraocular antibiotics for chemoprophylaxis. Our study was not without limitations. It was an openlabel nonrandomized study. The use of the stent in both groups could have mitigated the effect of the steroid on pressure. At baseline, the 2 groups were statistically different in terms of age, IOP, and baseline glaucoma medications. This difference at baseline might contribute to challenges in comparing medication reduction between the 2 groups. However, it should be emphasized that the study group represented the final 234 eyes that had the triamcinolone–moxifloxacin–vancomycin intravitreal injection immediately before the site transitioned to an injection containing only triamcinolone and moxifloxacin. No additional inclusion or exclusion criteria were used in the study group to prevent selection bias and to mimic the clinical use of the intravitreal injection approach. From this study, there are numerous avenues for further evaluation. Future studies could focus on the safety and efficacy of the currently used injection of triamcinolone and moxifloxacin without vancomycin. Additional research could explore the rate of pressure spikes in nonglaucomatous eyes versus glaucomatous eyes using the intravitreal approach. Previously, subconjunctival, intracameral, and transzonule intravitreal triamcinolone injections have been shown to be generally well tolerated without significant pressures spikes when administered in conjunction with phacoemulsification only.20,36,37 There have also been reports of significant pressure elevations after intravitreal steroid injection; however, these occurred when treating macular edema and retinal neovascularization in nonglaucomatous eyes.38 Although the most critical aspect of intravitreal administration is reducing the risk for infection, pain, and other adverse events, patient experience is also an important consideration. For some patients, the highest out-ofpocket expense in the entire process are the drops after surgery. This present study did not use surveys and/or reviews to assess patient satisfaction with either regimen. However, a previous study39 found that patients prefer the intravitreal injection over the topical regimen. In addition, triamcinolone injections often cause visual disturbances (eg, floaters), and using a clear steroid solution such as dexamethasone might alleviate this problem. Future studies focusing on the patient experience between the 2 approaches would be beneficial. With no exclusion criteria, this study mimics the clinical use of the intravitreal approach for delivering medications after cataract surgery. The early results from this study suggest that the intravitreal approach of administering medications might be a safe and effective option for glaucomatous eyes having cataract surgery with concomitant trabecular microbypass stent insertion. Although further studies are
required to solidify its role for both glaucomatous and nonglaucomatous eyes, our study suggests clinicians might consider the pars plana intravitreal injection of steroid and antibiotic as an alternative to topical regimens after cataract surgery.
WHAT WAS KNOWN Patient compliance with eyedrop medications is not outstanding. Intracameral and intravitreal antibiotics have been shown to be better than topical antibiotics in preventing postoperative endophthalmitis.
WHAT THIS PAPER ADDS Pars plana intravitreal injection of a steroid and antibiotics with a topical NSAID seemed to be a safe and effective option for reducing postoperative pain, inflammation, CME, and endophthalmitis. The intravitreal injection of triamcinolone–moxifloxacin–vancomycin did not contribute to significant pressure increases after cataract surgery in glaucomatous eyes.
REFERENCES 1. Kohnen T. Treating inflammation after lens surgery [editorial]. J Cataract Refract Surg 2015; 41:2035. Available at: http://www.jcrsjournal.org /article/S0886-3350(15)01186-4/pdf. Accessed November 7, 2017 2. Gollogly HE, Hodge DO, St Sauver JL, Erie JC. Increasing incidence of cataract surgery: population-based study. J Cataract Refract Surg 2013; 39:1383–1389. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles /PMC4539250/pdf/nihms711323.pdf. Accessed November 7, 2017 3. Braga-Mele R, Chang DF, Henderson BA, Mamalis N, Talley-Rostov A, Vasavada A, for the ASCRS Clinical Cataract Committee. Intracameral antibiotics: safety, efficacy, and preparation. J Cataract Refract Surg 2014; 40:2134–2142. Available at: http://www.ascrs.org/sites/default/files /resources/JCRS_December_2014.pdf. Accessed November 7, 2017 4. Shoss BL, Tsai LM. Postoperative care in cataract surgery. Curr Opin Ophthalmol 2013; 24:66–73 5. Lobo C. Pseudophakic cystoid macular edema. Ophthalmologica 2012; 227:61–67. Available at: http://www.karger.com/Article/Pdf/331277. Accessed November 7, 2017 6. Lane SS, Holland EJ. Loteprednol etabonate 0.5% versus prednisolone acetate 1.0% for the treatment of inflammation after cataract surgery. J Cataract Refract Surg 2013; 39:168–173 7. Kessel L, Tendal B, Jørgensen KJ, Erngaard D, Flesner P, Lundgaard Andresen J, Hjortdal J. Post-cataract prevention of inflammation and macula edema by steroid and nonsteroidal anti-inflammatory eye drops; a systematic review. Ophthalmology 2014; 121:1915–1924. Available at: http: //www.aaojournal.org/article/S0161-6420(14)00389-3/pdf. Accessed November 7, 2017 8. Miller JJ, Scott IU, Flynn HW Jr, Smiddy WE, Newton J, Miller D. Acuteonset endophthalmitis after cataract surgery (2000–2004): incidence, clinical settings, and visual acuity outcomes after treatment. Am J Ophthalmol 2005; 139:983–987 9. Korenfeld MS, Silverstein SM, Cooke DL, Vogel R, Crockett RS, the Difluprednate Ophthalmic Emulsion 0.05% (Durezol) Study Group. Difluprednate ophthalmic emulsion 0.05% for postoperative inflammation and pain. J Cataract Refract Surg 2009; 35:26–34 10. Packer M, Chang DF, Dewey SH, Little BC, Mamalis N, Oetting TA, TalleyRostov A, Yoo SH, for the ASCRS Cataract Clinical Committee. Prevention, diagnosis, and management of acute postoperative bacterial endophthalmitis. J Cataract Refract Surg 2011; 37:1699–1714. Available at: http: //ascrs.org/sites/default/files/resources/endophthalmitis.pdf. Accessed November 7, 2017 11. Vazirani J, Basu S. Role of topical, subconjunctival, intracameral, and irrigative antibiotics in cataract surgery. Curr Opin Ophthalmol 2013; 24:60–65 12. Ahmed Y, Scott IU, Pathengay A, Bawdekar A, Flynn HW Jr. Povidone-iodine for endophthalmitis prophylaxis. Am J Ophthalmol 2014; 157:503–504
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OTHER CITED MATERIAL A. Galloway MS, “Intravitreal Placement of Antibiotic/Steroid as Substitute for Postoperative Drops After Cataract Surgery,” presented at the ASCRS Symposium on Cataract, IOL and Refractive Surgery, Boston, Massachusetts, USA, April 2014. Abstract available at: https://ascrs.confex.com/ascrs /14am/webprogram/Paper8473.html. Accessed November 7, 2017 B. R Development Core Team. The R Project for Statistical Computing. Vienna, Austria, R Foundation for Statistical Computing. Available at: https://www.r -project.org/. Accessed November 7, 2017
Disclosures: Drs. Ibach, Schweitzer, and Berdahl are consultants to and speakers for Glaukos Corp. None of the other authors has a financial or proprietary interest in any material or method mentioned.
First author: Trevor Kindle, MD University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA