EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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20 | EYEWORLD | JUNE 2019 ASCRS NEWS The triamcinolone/moxifloxacin group did not prevent endophthalmitis against bacteria with high MICs, whereas the group with vancomycin did. This raises the question about the addition of vancomycin to dropless cataract surgery reg- imens. However, it is well reported that there is a risk of hemorrhagic occlusive retinal vasculitis with injection of vancomycin in the vitreous. 8,9 Another consideration is that use of inject- able agents may cost less to the patient, howev- er, there is an increased cost for the surgeon/ surgery facility. For a surgery center that has a high volume of cataract surgery, the extra cost can add up. While dropless surgery is a nice op- tion for patients from a safety and compliance standpoint, widespread adoption by surgeons may potentially be limited by cost at this time. In summary, the study suggests that intrav- itreal triamcinolone/moxifloxacin, along with a topical NSAID, should be considered a reason- able alternative for standard topical postoper- ative drops. Despite certain limitations of the study, Tri-Moxi with a topical NSAID can be considered a reasonable alternative to standard therapy following cataract surgery, particular- ly for those patients who may struggle or be considered unreliable to administer eye drops postoperatively. Additional surveillance with an extended follow-up of the two groups would likely be required for wide scale adoption. or contamination. Additionally, there is concern that dropless cataract surgery with moxiflox- acin monotherapy does not provide adequate prophylaxis for endophthalmitis. Patel et al. 6 presented a retrospective chart review of seven patients who experienced toxic posterior segment syndrome during an outbreak stemming from compounded triamcinolone/ moxifloxacin. These patients had immediate de- crease in vision after cataract surgery along with other visual complaints. Foveal RPE changes on clinical exam was noted in three patients and ellipsoid zone changes on OCT. ERG chang- es were noted in five patients. The authors postulated that the retinal damage was due to "poloxamer 407," which is used in compounded medications for solubility. Kishore et al. 7 reported four cases of acute onset postoperative endophthalmitis after cataract surgery and transzonular intra- vitreal Tri-Moxi. The authors express con- cern that the half-life of the typically injected 200 micrograms of moxifloxacin may be too short, resulting in premature clearance from the vitreous, theoretically preventing useful action in the anterior chamber. From a letter to the study authors, a basic science research lab published an experimental study in rabbits who received triamcinolone/moxifloxacin or triamcinolone/moxifloxacin/vancomycin and were then challenged with intravitreal S. aureus. continued from page 19 Comparative analysis of intravitreal triamcinolone acetonide/moxifloxacin versus standard peri-operative eye drops in cataract surgery Saman Nassiri, MD, Frank Hwang, MD, Jason Kim, MD, Bronson LeClair, MD, Eden Yoon, MD, Michael Pham, DO, Michael Rauser, MD J Cataract Refract Surg. 2019;45(6):760–765. n Results: A total of 1195 consecutive eyes (Group 1: 681, Group 2: 514) of 919 patients were included in the study. Postoperative anterior chamber cell reaction severity decreased by 34.0% and 35.7% 1 week and 1 month after surgery following triamcinolone acetonide/ moxifloxacin injection compared to standard eye drop therapy (P=.001 and P=.02, respectively). Group 1 was associated with increased severity of corneal edema (OR: 1.48; P=.001) on postoperative day 1, with no statistically significant difference at week 1 and month 1 (P=.25 and .48, respectively). There was no statistically significant difference in the rate of high IOP between groups at different time points postoperatively. n Conclusions: Triamcinolone acetonide/moxifloxacin injection is an effective method to control intraocular inflammation following cataract surgery. It is a promising substitute for standard eye drop therapy, especially in patients who have poor compliance with eye drop usage. n Purpose: To compare the effectiveness of intravitreal injection of triamcinolone acetonide/moxifloxacin (Tri-Moxi) to standard eye drop regimen in controlling postoperative inflammation, corneal edema and the rate of high IOP among cataract patients. n Setting: Loma Linda University Eye Institute, Loma Linda, California. n Design: Retrospective longitudinal comparative study. n Methods: We reviewed the electronic medical records of patients who underwent cataract surgery using triamcinolone acetonide/ moxifloxacin injection along with postoperative NSAID drop (Group 1). We compared this group to patients who received standard eye drop (Group 2) in terms of intraocular inflammation and corneal edema severity, and the rate of high IOP, postoperatively. References 1. Global Data on Visual Impair- ments 2010. WHO 2012. 2. Lindstrom R. Thoughts on Cata- ract Surgery: 2015. Review of Ophthalmology. March 9, 2015. 3. Vandenbroeck S, et al. Prevalence and correlates of self-reported nonadherence with eye drop treatment: the Belgian Compliance Study in Ophthal- mology (BCSO). J Glaucoma. 2011;20:414–21. 4. Endophthalmitis Study Group, European Society of Cataract & Refractive Surgeons. Prophylaxis of postoperative endophthalmi- tis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors. J Cataract Refract Surg. 2007;33:978–88. 5. Kiddee W, et al. Intraocu- lar pressure monitoring post intravitreal steroids: a system- atic review. Surv Ophthalmol. 2013;58:291–310. 6. Patel SB, et al. Toxic posterior segment syndrome after dropless cataract surgery with compound- ed triamcinolone-moxifloxacin. Retina. 2019. Epub ahead of print. 7. Kishore K, et al. Acute-onset of postoperative endophthalmi- tis after cataract surgery and transzonular intravitreal triam- cinolone-moxifloxacin. J Cataract Refract Surg. 2018;44:1436– 1440. 8. Nicholson LB, et al. Severe bilateral ischemic retinal vascu- litis following cataract surgery. Ophthalmic Surg Lasers Imaging Retina. 2014;45:338–42. 9. Witkin AJ, et al. Postoperative hemorrhagic occlusive retinal vasculitis. Expanding the clinical spectrum and possible associa- tion with vancomycin. Ophthal- mology. 2015;122:1438–51.