Eyeworld

117 EW FEATURE Dr. Liegner considered the idea of injecting the medication into the eye and inquired about what the retina specialists were using for patients with infections. "Moxifloxa- cin was the big one at that time, and vancomycin was always a favorite," he said, adding that for inflamma- tion they confirmed that they were using triamcinolone. He then set out to create a formulation that was PH proper, which would be held in solu- tion and could be delivered at a dose that cataract surgeons could use. This led to the development of the 2 intravitreal drugs made by Imprimis, Tri-Moxi and Tri-Moxi-Vanc. The technique takes patient compliance out of the equation. Dr. Liegner wonders whether lack of compliance causes infection or if it may be due to inadequate placement of drops. The intravitreal injection of medication assures physicians that the drugs are delivered exactly where they are needed. There are 2 primary techniques for using this—pars plana and transzonular. Dr. Liegner esti- mates that 60% of physicians use a transzonular injection approach, and 40% use the pars plana ap- proach. But it is the transzonular approach that he views as preferable. "People who do transzonular never go to pars plana," he said. He thinks that the advantage of the transzonu- lar approach is that it takes much less time, and there is no perforation of the eye or broken capillaries, hemorrhages, or pain associated with the injection. While many express concerns about the possibility of elevated intraocular pressure with the ap- proach, Dr. Liegner has not found this to be a big concern. "We have studied this, and there seems to be less than one-tenth of 1% of individ- uals who have a steroid response of elevated IOP," he said. Putting the medication in the eye can also fog the vision initially. "For the first 4–8 hours, you're not going to have that fabulous vision that some surgeons crave," Dr. Liegner said. Some patients see floaters for 2–3 weeks before the medicine gets absorbed. Dr. Liegner finds that the need for "rescue drops" in cases where intravitreal drugs have been used is dose-dependent. In his practice, the rate is about 2.6% of cases. Dr. Lindstrom views the ap- proach, which costs $20 for Tri-Moxi and $25 for Tri-Moxi-Vanc, as a huge financial boon for patients, since this is administered during the procedure and is currently bundled into the facility fee payment. "It saves patients sometimes hundreds of dollars," he said. Dr. Chang uses intracameral moxifloxacin, but in the absence of clinical studies he prefers topical postoperative anti-inflammatory drops. "Unless you do a fellow eye study comparing intravitreal injection in 1 eye to topical drops in the other, we simply have anecdotal impressions regarding our anti-in- flammatory regimens," Dr. Chang said. He uses generic topical NSAID and prednisolone acetate twice a day for 4 weeks in most of his cataract patients because it is easy to explain and remember. He refers patients to GoodRx.com to purchase these generics often at lower costs com- pared to their drug plans. Dr. Chang pointed out that every patient is different. "We published a study 3 showing that younger age and increasing axial length are sepa- rate and additive risk factors for a steroid response," he said. Dr. Chang therefore cautions against injecting triamcinolone in young myopes. "I use loteprednol when the patient has these risk factors or glaucoma and NSAID only for extreme axial myopes." He also individually varies and adjusts the anti-inflammatory treatment regimen. "I would love to see studies comparing the rates of rebound iritis, subclinical cystoid macular edema (CME), and steroid response with intravitreal triamcin- olone versus topical combination therapy." Richard Lewis, MD, Sacramen- to Eye Consultants, Sacramento, continued on page 118

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