EyeWorld Asia-Pacific December 2016 Issue

December 2016 26 EWAP SECONDARY FEATURE Views from Asia-Pacific LEE Mun Wai, MD Medical Director, Lee Eye Centre 44-46 Persiaran Greenhill, 30450, Ipoh, Perak, Malaysia Tel. no. 605-2540095 Fax no. 605-2540273 munwai_lee@lec.com.my P ostoperative endophthalmitis is the bane of every ophthalmologist’s existence and this dreaded complication, although extremely rare, has potentially devastating consequences for the affected patient (and surgeon)! Conventional strategies of prevention include: • Preoperative – management of lid disease, topical antibiotics, povidone iodine preparation of the surgical field • Intraoperative – careful lid draping, avoidance of posterior capsular compromise, intracameral antibiotics • Postoperative – topical antibiotics “Dropless prophylaxis” as described in this article uses a trans-zonular approach to administer a cocktail of triamcinolone and moxifloxacin and/or vancomycin at the end of cataract surgery. This novel technique has the potential to eliminate problems related to eyedrops usage such as toxic epitheliopathy, patient compliance, and perhaps cost. However, some points are worth considering: 1. The risk of secondary glaucoma from intravitreal triamcinolone 2. Inadvertent damage to zonules and resultant impact on intraocular lens stability 3. Potential breach of the anterior vitreous face and vitreous prolapse into the anterior chamber or wound 4. Use of Vancomycin and potential for Haemorrhagic Occlusive Retinal Vasculitis. Up to one-third of normal eyes may have increase in intraocular pressure (IOP) after topical steroid use 1 and intravitreal triamcinolone can do the same in almost 50% of eyes 2 . No doubt the majority of these are adequately managed with topical glaucoma medications but that would mean that this “dropless” technique may only be applicable in half of our patients. Of note from the latter study 2 , 8% of eyes who were not receiving glaucoma medication at entry into the study continued to receive glaucoma medication 3 years after triamcinolone injection. In my opinion, the significant concerns about IOP will limit the applicability of this “dropless” technique. In our centre, we routinely use gentamicin in our infusion as well as intracameral moxifloxacin for cataract surgery. Since the adoption of this practice, we have not had a case of endophthalmitis in our last 10,000 procedures. Endophthalmitis prophylaxis is essential for any intraocular procedure and even more so since the “anti-VEGF revolution”. Conventional strategies for endophthalmitis prevention are still the gold standard and will only be successful when applied together with a meticulous attitude towards preoperative, intraoperative, and postoperative care. References 1. Armaly MF. Effect of corticosteroids on intraocular pressure and fluid dynamics. I. The effect of dexamethasone in the normal eye. Arch Ophthalmol . 1963;70:482. 2. Gillies MC, et al. Safety of an intravitreal injection of triamcinolone. Arch Ophthalmol. 2004;122:336-340. Editors’ note: Dr. Lee declared no relevant financial interests. Robert T. ANG, MD Senior Consultant, Asian Eye Institute 8th Floor Phinma Plaza Rockwell Center, Makati City, Philippines Tel. no. +63-2-8982020 Fax no. +63-2-8982002 angbobby@hotmail.com A fter an incident-free cataract surgery, the worst thing that can happen is an infection. A conscious effort is made by all surgeons beginning at the preoperative examination all the way until after-surgery care to mitigate this unwanted and difficult-to-predict complication. For the usual cataract case, our current practice involves povidone iodine lid scrub and fornix wash immediately prior to surgery and postoperative use of fourth generation fluoroquinolone (Zymar, Allergan, Dublin), prednisolone acetate (Pred Forte, Allergan) and ketorolac (Acuvail, Allergan) for 4 weeks. I personally have had no infections yet with this regimen. I personally tried intracameral moxifloxacin (Vigamox, Alcon, Fort Worth, Texas) immediately after surgery but have had some cases of iritis and tonic pupil so I stopped using this drug. I have also used intracameral diluted vancomycin on some cases which I perceive as high risk like those with recurrent blepharitis prior to surgery and have not encountered problems using this drug. I believe the questions that confront us are do we want to change our protocol and inject antibiotics into the eye so we can spare the patient from placing eyedrops after surgery or do we believe placing antibiotics directly into the eye in addition to the drops we normally give provide more protection against postoperative infection. Since there is no hard evidence published in the literature that implicitly recommends this protocol shift, the decision remains with each surgeon. In this article, they inject the antibiotic/steroid drug into the vitreous through the inferior zonule using a needle. This is very different from how we inject intracameral antibiotics which is into the anterior chamber using a cannula through one of the corneal incisions. I find that the technique described in the article introduces a new level of risk in terms of possible zonular damage and increase in intravitreal pressure. Intentionally violating the barrier between the anterior and posterior chamber through the zonules makes me very uncomfortable. Any mistake resulting in damage to the zonules may affect IOL position and may be very difficult to repair. Adding volume to the vitreous may cause high intraocular pressure which may need eyedrops to resolve, defeating the purpose of removing eyedrops postoperatively which was the original intent of the antibiotic injection in the first place. The article likewise mentions that the triamcinolone component is for lessening postoperative inflammation for a dropless postoperative course but some cases still required anti-inflammatory eyedrop medications. At this point in time, my personal opinion is the risk-to-benefit ratio does not justify introducing this protocol of injecting antibiotic/steroid cocktail into the vitreous. I would continue using postoperative eyedrops and encourage compliance by explaining the importance of these drops to patients. I am more inclined to consider injecting antibiotics into the anterior chamber when the need arises or when more evidence in the large studies are published in the literature because this technique is easy and does not add any risk to the patient’s eye. Editors’ note: Dr. Ang has no financial interest related to this article but receives research grants from Allergan. Preventing - from page 25