Eyeworld

115 EW FEATURE AT A GLANCE • text goes here • text goes here • text goes here a standard, injecting 2.5–3 mm back, finding the pars plana won't be per- fectly precise. It is essentially a blind maneuver, which is why I choose to inject transzonularly. Still, I don't think there is any huge disadvan- tage to the pars plana approach, other than making another opening into the eye. With a transzonular approach, you are already in the eye to remove the cataract," Dr. Gallo- way said. All-in-one All-in-one injected meds are allur- ing for their practicality, but they also need to live up to a slew of demands. According to Dr. Gallo- way, 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 com- monly prescribe both antibiotic and corticosteroid drops for patients to self-administer for days to weeks postoperatively, often including additional non-steroidal anti-inflam- matory (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 rea- sons. TriMoxi is a compounded triamcinolone acetonide/moxi- floxacin 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 intravit- real 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 Uniform epithelium removal in only 5 - 7 seconds Corneal Xlinking, PRK Advanced Surface Ablation Improved clinical outcomes of CXL and PRK with Amoils Epithelial Scrubber ds Visit us at ASCRS 2017 in booth 1107 Minimize total procedure time Avoid alcohol damage to surrounding tissue No need for subsequent scraping T. 800.461.1200 www.innovativexcimer.com order online www.innovativexcimer.com AMOILS EPITHELIAL SCRUBBER AMOILS www.innovativexcimer.com continued on page 116 Francis Mah, MD, director of corne- al and external disease and co-di- rector of refractive surgery, Scripps Clinic, La Jolla, California, spoke to EyeWorld about which method they use and why. Transzonular approach A controversial method of adminis- tering prophylactic meds after cata- ract surgery involves the transzonu- lar injection of a triamcinolone/ moxifloxacin combination, TriMoxi (Imprimis Pharmaceuticals, San Di- ego) into the anterior vitreous, with or without vancomycin (TriMox- iVanc, Imprimis Pharmaceuticals). While some surgeons prefer to avoid any unnecessary manipulation of the zonule fibers due to concerns of preserving their structural integ- rity and potentially creating new problems in the eye, Dr. Galloway sees this as a misconception. "My own personal approach is almost 100% transzonular. It is very safe and does not damage the zonules. The biggest disadvantage of the ap- proach is that some surgeons might not feel comfortable about going through the zonules, because we are taught in training not to damage the zonules and be wary of going into the vitreous. But, it is very safe once you learn the technique and know how to do it. I don't see any other disadvantage, whatsoever," he said. Dr. Galloway and his colleagues have successfully used TriMoxi for cataract surgery in about 20,000 eyes. His technique involves gently stretching the ciliary sulcus and zonules with viscoelastic and direct- ing the cannula under the iris and above the anterior capsule. The can- nula is then advanced through the zonules, which separate but do not break, and into the vitreous. A visual movement or release of the lens capsule sometimes confirms zonu- lar penetration. TriMoxi is injected slowly and at a constant rate. "The pars plana approach is also very effective and quite prominent in the U.S. The only downside is that there can be some discomfort to the patient. In addition, anatom- ically we don't always know the exact location of the pars plana. In some patients, it is more anterior or posterior, and since we are applying

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