EyeWorld Asia-Pacific June 2017 Issue

June 2017 EWAP SECONDARY FEATURE 29 Views from Asia-Pacific Soosan JACOB, MS, FRCS, DNB Director and Chief, Dr. Agarwal’s Refractive and Cornea Foundation; Senior Consultant, Cataract and Glaucoma Services Dr. Agarwal’s Group of Eye Hospitals 19 Cathedral Road, Chennai, India PIN 600086 Tel. no. +914428112811 dr_soosanj@hotmail.com G oing dropless is indeed a dream that many ophthalmologists, patient, and patient care providers as well as insurance companies would love to have as reality, and it certainly seems that this may now be possible thanks to the newer combination medications available for injection into the vitreous or anterior chamber. The advantages seem obvious in terms of better patient compliance and convenience, lower cost for the patient, the certainty of medication compliance, and the prevention of endophthalmitis, cystoid macular edema, and inflammation with just one intervention. Caution however still needs to be exercised as going dropless in the postoperative period may also be associated with many serious complications that can sometimes be difficult to handle. This may be either secondary to problems associated with the route of administration or complications associated with the medication/formulation that is used. The trans-zonular approach can cause possible damage to the capsule–zonular complex and I personally would not tend towards using it. The pars plana approach, though easier and safer, is not a route that every anterior segment surgeon may be comfortable with. Complications such as retinal detachment and endophthalmitis that may be associated with either of the abovementioned routes of administration should be kept in mind, more so if the formulation is compounded by the local pharmacy. Intracameral injection has the disadvantage of rapid disappearance of the drug, leaving the patient at a higher risk of infection/ inflammation if not supplemented by topical drops. In addition, there are obvious complications associated with certain drugs such as hemorrhagic occlusive retinal vasculitis (HORV) that has been postulated to be associated with vancomycin and steroid-induced glaucoma secondary to triamcinolone that can become very difficult to manage. The risk of a rise in IOP and breakthrough inflammation despite the use of medications are reasons that these patients will need to be kept on close follow up. A decrease in vision in the immediate postoperative period with certain preparations is also a disadvantage. Every surgeon should therefore carefully consider both the pros and the cons of going dropless before making a decision. It is also important to discuss the advantages and disadvantages with the patient and take an informed consent if dropless cataract surgery is being planned. Editors’ note: Dr. Jacob declared no relevant financial interests. All-in-one All-in-one injected meds are alluring for their practicality, but they also need to live up to a slew of demands. According to Dr. Galloway, a single injection of TriMoxi is not only practical but also far less complicated to do than some might think, and extremely effective in the prevention of inflammation, cystoid macular edema (CME), and endophthalmitis following cataract surgery. Cataract surgeons commonly prescribe both antibiotic and corticosteroid drops for patients to self-administer for days to weeks postoperatively, often including additional non- steroidal anti-inflammatory (NSAID) drops as well. The typical regimen involves antibiotic drops for a week, a steroid taper over a month, and an NSAID drop for 4–6 weeks, with the drop frequency varying from once to four times per day, which can be challenging to elderly patients for a range of reasons. TriMoxi is a compounded triamcinolone acetonide/ moxifloxacin combination of 15 mg/1 mg/ml combined into one stable product. The injection delivers 0.2 ml solution through a 30-gauge cannula into the anterior vitreous, either transzonularly or through the pars plana. He prefers the intravitreal drug effect to drugs given, for instance into the anterior chamber, where an antibiotic may last for only a few hours, while the same drug will have a lasting effect of 12 hours or more in the vitreous. Dr. Galloway said that only a very small percentage of his patients require additional drops after surgery. “Overall, it is around 5% of people who develop some rebound inflammation and need a drop supplement. In my own personal practice, it is closer to the 2% mark, but some others have reported it to be as high as 10%. The difference is that the patient only has to be on one drop postoperatively that he takes a couple of times a day, and within a week or so the inflammation is gone. It is very easy to treat and does not involves weeks of different drops given at different intervals, so it is still better for the patient, even those that break through,” he said. Postoperative vision varies, mostly because TriMoxi and TriMoxiVanc are opaque and can be unsatisfying for patients and for surgeons who value immediate postoperative visual results as a measure of surgical success. “We are putting a milky substance into the vitreous, so vision on the day of surgery varies tremendously. I’ve seen same-day postoperative patients who have very poor vision and can only count fingers to others who have 20/20. It boils down to whether the TriMoxi is in front of the macula or not. If it is out of the way, they are going to see some floaters, and if it is in the way, they may have poor vision for a few hours. I tell my patients here to expect that this is the tradeoff for getting out of drops. Expect poor vision on the day of surgery, and expect some floaters on the top part of vision typically for 1 to 3 days, after which it will absorb and vision will clear,” Dr. Galloway explained. Overall, a one-shot surgical prophylaxis regimen gives patients and physicians significant peace of mind. In addition, TriMoxi saves the patient between $300 and $500 on postoperative drops. “There is a substantial savings to the patients using TriMoxi. It actually costs the surgery center about $20 for continued on page 30