Eyeworld

EW CATARACT 60 March 2017 Pharmaceutical focus by Maxine Lipner EyeWorld Senior Contributing Writer keeps on getting diluted out," Dr. Devgan said. "That's why the parti- cles don't stay in there forever." The vitreous, however, doesn't turn over. So, when you inject triamcinolone, it will remain in place for at least a couple of weeks, he noted. "Patients will notice in their vision large float- ers, which is not great for patient satisfaction," Dr. Devgan said. In addition, he points out that you can't put anything through the zonules without breaking them. Dr. Devgan cites how the thin dye trypan blue remains in the anteri- or chamber when used for white cataract cases. "The injection of triamcinolone or the Kenalog (tri- amcinolone acetonide, Bristol-My- ers Squibb, New York) is a thick suspension with big particles in it," he said. "There is no way it will go through zonules unless I focally break the zonules and I know that's true because the blue dye doesn't go through." He is also concerned about what might happen in cases involving steroid responders and for this reason, he avoids the trans-zonular approach. When it comes to postoperative drops, Dr. Devgan favors the use of Durezol in his private practice. How- ever, at the UCLA hospital where he teaches residents, they use generic prednisolone acetate 1% due to cost constraints. "The Durezol is twice as strong or maybe more than twice as strong as the Pred Forte [predniso- lone acetate, Allergan, Dublin]," he said. "That means I can dose it less frequently in my private practice." Richard Hoffman, MD, clinical associate professor of ophthalmol- ogy, Oregon Health and Science University, Portland, likewise prefers the Durezol but typically prescribes generic steroids for his patients due to cost factors. "Most of my patients balk at a $150 prescription for a small 3 ml bottle," Dr. Hoffman said. Instead, he tends to use the generic prednisolone, sometimes in con- junction with injecting intracameral steroids transzonularly. "It's very nice for patients because they get intracameral steroid and antibiotic, so theoretically the risk of endoph- thalmitis should be lower," he said. With the intracameral approach, Dr. Hoffman finds that there is about a 10% failure rate, with only about 1 in 10 needing to be placed on a generic topical steroid. However, postop day 1 the eyes are quiet and there is minimal inflammation, with most patients thrilled to be seeing 20/20. The eyes are particularly quiet because the triamcinolone particles are inside, he explained. "They are embedded on the surface of the iris for a few days," he said. "So, for a few days, you have around-the- clock constant levels of steroids in the anterior chamber of the eye." Meanwhile, if you give a drop twice a day, peak level is attained about 5 minutes after instillation and then slowly comes down over the next 12 hours, he continued. Although Dr. Devgan likes the intracameral approach, he is not a fan of injecting such agents transzonularly. "The intracameral steroids are put into the anterior chamber at the end of surgery and cause a little snow-globe effect that lasts for maybe a couple of days," he said, adding that at best such particles are there for about 1 week. He likens the anterior chamber to a bathtub that just keeps running. "Whatever you put in there just the tiny bit that we can't even see that we leave behind, those are pro- teins that the immune system has never seen," Dr. Devgan said. "The eye creates a lot of inflammation in response to seeing those proteins for the first time." In addition, surgery itself induces inflammation, and the eye has to accept this manmade lens as its own, he continued. This often means relying on ste- roids, at times administered during the surgery as well as postoperative- ly, in the form of drops. Dr. Devgan typically uses a combination of intracameral steroids and postoper- ative drops for his cataract patients. He injects a small amount of pre- servative-free Triesence (triamcino- lone, Alcon, Fort Worth, Texas) into the anterior chamber at the end of surgery and then prescribes Durezol (difluprednate, Alcon) postoperative- ly, twice a day for the first week and then once a day for the week after. He relies on the intracameral steroids in nearly all cases to assure that patients are happy after surgery. With this, Dr. Devgan finds that on Two ophthalmologists discuss the role of steroids D espite how good cata- ract surgery has become, practitioners must still contend with tamping down some inflammation, making at least some steroid use frequently warranted, according to Uday Devgan, MD, clinical profes- sor of ophthalmology, David Geffen School of Medicine at UCLA, chief of ophthalmology, Olive View UCLA Medical Center, and in private practice, Devgan Eye Surgery, Los Angeles. "I'd say well over 95% [of practitioners] would use it for all cataract postoperative patients," he said, adding that the goal is to quell inflammation of the eye resulting from its response to exposure to human lens proteins. No matter how skilled the surgeon, there are usually some remnants of such lens protein that remain after phacoemulsification. "We get 99% of the cataract out, but Cataract removal on steroids The patient with a cataract and pseudoexfoliation syndrome will need steroids to quell inflammation after cataract surgery. Source: Uday Devgan, MD

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