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No endophthalmitis seen in case series of ‘no-drop’ cataract surgery
The surgeon administers transzonular triamcinolone acetate and moxifloxacin at the conclusion of the procedure.
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An 81-year-old white female presented as a new patient for a cataract evaluation after being referred by a friend who recently had cataract surgery through our practice. She called our office after hearing that her friend used no eye drops (except for artificial tears) after her surgery and wanted to know if she would be eligible for the same care. She admitted that she had been diagnosed with cataracts in her early 70s, but dreaded the idea of having to put eye drops in herself. She has no family in the area to depend on and has severe arthritis in her hands.
Postop transzonular therapy vs. drops
In most cases, we administer a formulated mixture of triamcinolone acetate and moxifloxacin, which we call trimox, in a transzonular fashion into the anterior vitreous at the conclusion of uneventful cataract surgery. This formulation takes the place of topical antibiotics and anti-inflammatory drops in about 90% of our patients who undergo cataract surgery or clear lensectomy by our chief surgeon.
Richard B. Mangan
I first reported on this type of drug delivery method in the June 2007 issue of Primary Care Optometry News in “No patient compliance needed with intraoperative drug” (pages 25 and 26). At that time, we retrospectively looked at 500 consecutive cases involving a similar formulation (using gatifloxacin instead of moxifloxacin). No cases of endophthalmitis were reported.
While our study had a relatively low N value, the results compare favorably to the reported incidence rate of endophthalmitis after cataract surgery of 0.05% to 0.37% (Aaberg, et al.; Javitt, et al.; Kattan, et al.).
Evidence grows
Growing evidence supports the idea of alternative drug delivery methods of antibiotics and steroids, while questioning the need for prescription eye drops surrounding cataract surgery.
Koch and colleagues were awarded best paper of the 2005 American Society of Cataract and Refractive Surgery-American Society of Ophthalmic Administrators symposium, for “Intracameral injection studied to replace post-op eye drops.” With 1,100 cases in their series with formulated “trigat” (triamcinolone/gatifloxacin), the clinicians had no cases of traditional postoperative cystoid macular edema (CME) and no cases of infectious endophthalmitis.
Friling and colleagues recently published what is believed to be the largest prospective study of endophthalmitis (135 cases out of 464,996 surgeries) after cataract surgery. The data from this 6-year Swedish study offered a few compelling conclusions.
A cannula is placed between the anterior capsule and the iris, taking care to extend it past the peripheral edge of the capsule.
Images: Mangan RB
As the injection begins, a small amount of medication is refluxed into the anterior chamber. This may be visible postoperatively as “pseudohypopyon.”
The incidence rate of endophthalmitis in Sweden has consistently been 0.05% or lower since physicians have universally switched to the use of intracameral antibiotics. In addition, incidence rates are lower for those having surgery younger than the age of 85 and when there is no posterior capsular rupture. It was also found that short-term topical antibiotics given in addition to the intracameral regimen “did not confer a clear-cut benefit.”
Raen and colleagues compared postoperative endophthalmitis rates from the years 2004 to 2011. Beginning in 2007, they stopped prescribing topical antibiotics in conjunction with intracameral cefuroxime.
From 2004 to 2006, 7,123 patients undergoing cataract surgery received intracameral cefuroxime plus topical chloramphenicol plus a steroid. From 2007 to 2011, 8,131 received intracameral cefuroxime and steroid.
The authors concluded that adding topical chloramphenicol showed no additional benefit in reducing endophthalmitis rates.
As trimox is injected into the vitreous cavity, the cornea is deformed to allow viscoelastic to exit the corneal wound and equalize the pressure in the eye.
The majority of the medication is injected into the vitreous cavity. Initially it is concentrated in the anterior vitreous space.
The characteristic white pupil is evidence of the quick diffusion throughout the eye and has become the familiar endpoint of an uncomplicated cataract surgery.
Shorstein and colleagues reported their evolving experience with intracameral injection alone and in combination with differing topical antibiotics used postoperatively. Of 16,264 cases, 19 cases of endophthalmitis were reported. The authors appropriately are quick to point out that this was not a randomized controlled study. Nonetheless, certain inferences were made.
“Systematic adoption of intracameral antibiotics at the end of cataract surgery was associated with a lower rate of endophthalmitis at a large surgery center in Northern California,” they wrote. “Intracameral injection may be particularly effective in patients who sustain posterior capsular rupture. Intracameral injection alone, without additional perioperative antibiotic drops, may be highly protective against endophthalmitis.”
Negi and colleagues performed a randomized controlled trial comparing steroid eye drops to sub-Tenon steroids in the prevention of postoperative CME after cataract surgery. Fifty-four patients were randomized to either topical betamethasone sodium phosphate 0.1% drops or 20 mg to 30 mg of sub-Tenon triamcinolone. They reported no statistically significant difference between the two groups in visual outcomes and adverse events. They concluded that sub-Tenon triamcinolone was safe and effective surrounding uneventful cataract surgery and could be used as an alternative to drops when compliance is a concern.
Patient discussion
I explained to our patient that we originally started offering trimox out of concern that patients were not instilling their drops accurately and in a timely manner, thereby increasing the risk of postoperative infection. Additionally, friends and family no longer have to alter their schedules to accommodate a loved one who needs assistance with his or her drops. Many barriers to drop compliance exist, and severe arthritis is just one of them.
All patients who report an allergy to fluoroquinolones are automatically excluded from the trimox protocol.
Clearly, for no-drop cataract surgery to become mainstream we need one or more controlled longitudinal studies comparing the parenteral (intracameral, sub-Tenon and/or transzonular) delivery of formulated antibiotic/steroids with and without prescription topical agents.
With that said, the anecdotal evidence is mounting and, at minimum, when confronted with the patient for whom drop adherence after surgery is a concern, these alternative routes of medication administration should be considered.
The surgeon administers transzonular triamcinolone acetate and moxifloxacin at the conclusion of the procedure.
References:
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Disclosures: Mangan has no relevant financial interests to disclose.