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Intracameral corticosteroid after phacotrabeculectomy reduces anterior chamber inflammation
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Eyes injected with triamcinolone acetonide directly into the anterior chamber at the conclusion of combined trabeculectomy and cataract surgery achieved better visual acuity and less anterior chamber inflammation than eyes that did not receive any triamcinolone acetonide, according to a study.
“We are often requested to perform cataract and glaucoma surgery concurrently,” lead author Bingsong Wang, MD, PhD, an associate professor of ophthalmology at Beijing Shijitan Hospital, Capital University of Medical Sciences, Beijing, told Ocular Surgery News. “However, combined phacotrabeculectomy is not as satisfactory as expected because of postoperative anterior chamber reactions. Some postoperative eyes even suffer from fibrinous uveitis.”
Controlling inflammation
Wang and colleagues sought to find a way to control postoperative inflammation.
“Naturally, we thought of steroid with marked anti-inflammatory action,” she said. “Triamcinolone acetonide (TA) has already been used through intravitreal injection to treat posterior segment diseases, and a single intraoperative intravitreal injection of TA was verified to be safe and efficacious during phacoemulsification in patients with uveitis.”
Bingsong Wang
This led the investigators to speculate if triamcinolone acetonide could be used off label and injected directly into the anterior chamber at the conclusion of surgery to adequately control postoperative inflammation with little or no complications. Reviewing the literature gave them encouragement.
“Recently, TA has been used directly in the anterior chamber following cataract surgery and was shown to be safe and effective,” Wang said.
Potential complications were also contemplated.
“Steroid-induced glaucoma and steroid-induced cataract were out of the question because the crystalline lens has been removed and a new filtration channel has been built,” Wang said.
The prospective, randomized, controlled study, which appeared in the Journal of Cataract and Refractive Surgery, divided 126 patients into four groups: Group A received intracameral preservative-free triamcinolone acetonide 0.5 mg via the paracentesis incision, group B received triamcinolone acetonide 1 mg, group C received triamcinolone acetonide 2 mg, and group D, the control group, did not receive any triamcinolone acetonide.
For all four study groups, the postoperative corrected distance visual acuity (CDVA) at all follow-up intervals (1, 7, 14 and 28 days) was statistically significantly better than the preoperative CDVA. On day 1, the three groups treated with triamcinolone acetonide had a better CDVA than the control group, and there was no statistically significant difference among the three triamcinolone acetonide groups.
At day 7, group B achieved better CDVA than the other three groups, and there was no significant difference among group A, group C and group D.
Concerning inflammation, 1 day after surgery the three triamcinolone acetonide groups had less anterior chamber flare than the control group, and there was no statistically significant difference between the three treated groups. However, at day 7, group B and group C had less anterior chamber flare than group A. Then, at day 14, all four groups had mild flare, with no statistically significant difference among the groups.
Observations
“The first day after surgery, the clear cornea and anterior chamber did surprise us,” Wang said. “The strong anti-inflammatory action of TA was a bit beyond our expectation.”
Also, at the beginning of the study, one of the surgeons injected approximately 3 mg of triamcinolone acetonide into the anterior chamber.
“The next day, she found that the TA particulates deposited on the surface of the iris and IOL. The patient had blurred vision,” Wang said. “One week later, the particulate was absorbed, and the patient’s visual acuity increased.”
The investigators had to make adjustments to properly control the injection dosage.
To increase the efficacy of the injection, Wang recommended that surgeons tell their patients to maintain a supine position with the head up so that the triamcinolone acetonide can be absorbed efficiently and quickly.
“Intracameral injection TA is off-label use, and extreme caution should be exercised,” she said. “Patients should be informed with relevant information, and a patient-informed consent should also be obtained.”
Wang and colleagues are pursuing a follow-up study to evaluate the long-term effect of triamcinolone acetonide on both visual acuity and IOP.
“Being a steroid, TA should have some anti-fibrosis effect. It can also decrease the macular edema,” she said. – by Bob Kronemyer