Eyeworld

117 EW FEATURE April 2017 • Controversies in cataract surgery the murkiness of triamcinolone that obscures early postoperative vision and requires transzonular or pars plana application, dexamethasone is clear and can be left in the anterior chamber without concern—even in glaucoma patients. When he was at the University of Pittsburgh, Dr. Mah's colleagues published a paper with higher amounts of intracam- eral dexamethasone in glaucoma patients being safe and effective following routine cataract surgery. Dr. Mah thinks that anterior segment surgeons who do not nor- mally deal closely with the vitreous might feel uncomfortable and avoid vitreous manipulations if possible. Surgeons unaccustomed to working beyond the anterior segment might feel uncomfortable trying to per- form a transzonular or pars plana drug delivery approach, which may invalidate TriMoxi from their list of options, while intracameral appli- zonules by injecting something transzonularly can potentially affect the effective lens position and the determination of the best possible postrefractive outcomes. He eluci- dated that putting something into the anterior vitreous has anecdotally affected the potential space between the posterior capsule and anterior hyaloid face, altering the desired refractive outcome by causing a myopic result of several Crystalens (Bausch + Lomb, Bridgewater, New Jersey) or Trulign (Bausch + Lomb) cases, where the posterior capsule was pushed forward due to medica- tion placed transzonularly into the potential space, pushing the implant lens forward. "My choice is moxifloxacin with dexamethasone (Ocular Science), which I inject directly into the ante- rior chamber after cataract surgery. The combination consists of 0.5% moxifloxacin and 0.1% dexameth- asone, giving 0.15 cg of this mix. What gets into the eye would be ap- proximately 750 micrograms of the moxifloxacin and 150 micrograms of the dexamethasone. After I've taken the cataract out, I check my inci- sions like I normally would to make sure the incisions are water-tight. Then I use a 1cc syringe and an AC cannula (27 or 30 gauge) through the paracentseis site, and go right underneath the anterior capsule and inject," he said. According to Dr. Mah, dexa- methasone is a preferable choice over triamcinolone due to its shorter half-life of 7 to 8 days, volumi- nous data of use in ophthalmology compared to all other steroids, and clarity of the preparation. As most cataract patients would not require steroids after surgery for any longer than 2 weeks, dexamethasone would very likely be sufficient coverage. A huge advantage is that compared to cation would be more attractive to them. "Injecting into the anterior capsule is not challenging for anteri- or segment surgeons. That's just my own assessment. Obviously there are surgeons out there successfully using TriMoxi and other formulations using vitreous approaches which is great, but for me, I just don't feel as comfortable and I'm glad I don't have to learn a new technique or disturb the zonules or vitreous," Dr. Mah said. EW Editors' note: Dr. Galloway has finan- cial interests with Imprimis Phar- maceuticals. Dr. Mah has financial interests with Bausch + Lomb (Bridge- water, New Jersey), Novartis (Basel, Switzerland), Ocular Science (Manhat- tan Beach, California), and PolyActiva (Melbourne, Australia). Contact information Galloway: eyeguy@frontiernet.net Mah: mah.francis@scrippshealth.org

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