Dropless Cataract Surgery

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Article initiated by:
Brad H. Feldman, M.D., Michelle Diamandi
All contributors:
Michelle Diamandi, Brad H. Feldman, M.D., Derek W DelMonte, MD
Assigned editor:
Derek W DelMonte, MD
Review:
Assigned status Up to Date
 by Derek W DelMonte, MD on May 21, 2024.


Overview

Background

Cataract surgery is one of the most commonly performed surgical procedures in the United States and across the world. Among the most concerning complications of cataract surgery are postoperative infection and inflammation.

Postoperative infectious endophthalmitis

  • The most devastating but rare complication of cataract surgery is postoperative endophthalmitis, which refers to inflammation of anterior and posterior chambers of the eye. This inflammation may be sterile or associated with infection[1]. Infectious endophthalmitis occurs at a background rate of approximately 1 in 5,000 surgeries, but this varies across the literature. Aggressive infectious endophthalmitis can result in blindness. Postoperative endophthalmitis requires urgent recognition, diagnosis, and treatment which may consist of a "tap and inject" or a pars plana vitrectomy.
  • Antibiotics administered intraoperatively during cataract surgery have been proven to decrease the risk of endophthalmitis.[2]
  • In the United States, moxifloxacin is most commonly administered during cataract surgery due to commercial availability of preservative free moxifloxacin eye drops in concentration of 0.5%. For the majority of countries, cefuroxime is most commonly used. The suggested dose of 0.5% moxifloxacin (ex. Vigamox) solution is 0.15-0.5mg/0.1mL.[3]
    • Shorstein and Gardner flushing model (2019): inject 0.5%/0.1mL and flush 0.15%/0.5mL of moxifloxacin.[3]
    • A single-use vial form of moxifloxacin is also available in a concentration of 5mg/mL through a compounding pharmacy (Imprimis Pharmaceuticals Inc., San Diego, CA, USA).[3]
    • Moxifloxacin is very well tolerated– studies have reported only mild increases in macular thickness and very few cases of bacterial infections such as staphylococcus epidermidis after moxifloxacin injection during surgery.[3]

Postoperative intraocular inflammation

  • Iritis (ciliary flush, irregular miotic pupil, reduced vision, pain, light sensitivity)
  • Cystoid macular edema (distorted or blurred central vision, pink-tinted or dim vision, light sensitivity, or asymptomatic)
    • In OCT, CME presents as retinal thickening with intraretinal cystic areas of low reflectivity in the outer plexiform layer.[4]
  • Toxic anterior segment syndrome (TASS)

Postoperative Regimens

The traditional and most common cataract surgery post-op regimen involves use of topical steroid and topical non-steroidal eye drops for weeks (usually one month) after cataract surgery. Drops typically taper down gradually as the number of weeks after surgery increases. There is no universal consensus of postoperative drop regimens.

Just like antibiotics, corticosteroids (e.g. triamcinolone acetonide) may be administered intraoperatively during cataract surgery at the end of cataract extraction via different injection sites in the eye, most commonly subconjunctival, sub-tenon, or intravitreal sites. Corticosteroids may also be administered intraoperatively via intracameral injection (Dexycu[5]), or an intracanalicular drug-eluting insert (Dextenza).

The use of intraoperative steroids (achieved via various methods) in place of postoperative topical steroids is known as “dropless cataract surgery”.

Patient Selection

Indications

  • Compliance with topical treatment can be difficult for patients with arthritis, memory loss, cognitive impairment, and/or with need of physical assistance when administering drops into their eyes.
  • Patients undergoing cataract surgery who are otherwise healthy may have a personal preference to skip or limit the use of topical anti-inflammatory eye drops after surgery if given the choice.
  • Topical therapies have the potential for adverse reactions. Topical NSAIDs, which suppress cyclooxygenases (COXs), can cause keratopathy, and, rarely, can cause corneal ulceration or corneal melts.[6]
  • Dropless cataract surgery can also be more cost-efficient for patients.

Contraindications

  • Glaucoma patients and steroid responders who are at risk of IOP rise after cataract surgery are not ideal candidates for sub-tenon or intravitreal steroid injection during cataract surgery.[7] These patients may be better suited for subconjunctival steroid injection, as subconjunctival TA can be removed surgically with a simple conjunctival excision should IOP rise after surgery.[8]
  • Younger patients (<51 years) may have an increased risk of IOP elevation after prolonged steroid use and therefore should be approached with caution.[9]
  • Patients with high myopia (axial length of at least 29.0 mm) may also have an increased risk of postoperative steroid response.[10]
  • Patients with narrow palpebral fissures that would make injection difficult are also not ideal candidates.
  • Patients allergic to any component of the injection are not ideal candidates for dropless cataract surgery.

Surgical Technique

Subconjunctival injection

Subconjunctival injections are given either under the epibulbar conjunctiva (lining the eyeball conjunctiva) or under the palpebral conjunctiva (lining the eyelid conjunctiva), allowing drugs to bypass the epithelium.[11] Subconjunctival steroid injection is of particular interest since it is very minimally invasive, although aesthetically there is an increased chance of redness immediately following surgery (e.g. from subconjunctival hemorrhage).

Sub-tenon injection

Sub-tenon injections are administered in the sub-tenon space which lies between the tenon capsule and the sclera.[12] Subconjunctival injections may be preferred over sub-tenon injections due to needle tip visibility during injection and ease in monitoring the postop steroid depot as it dissolves over time.[13]

Intravitreal injection

Intravitreal injections are administered through the pars plana into the mid-vitreous cavity.[14] Administering medication into the vitreous is advantageous compared to topical eye drops because it protects directly against retinal inflammation. However, complications in the retina after intravitreal injection, such as infection, pose a higher risk of devastating vision loss compared to other injection sites or topical eye drops.

Dexycu intracameral drug delivery suspension

Dexycu (EyePoint Pharmaceuticals, Watertown, Massachusetts, USA) is an intracameral dexamethasone drug delivery suspension which provides gradual drug release upon a single treatment injection.[5]

Dextenza intracanalicular insert

Alternatively, Dextenza (Ocular Therapeutix, Inc.) is a resorbable drug-eluting insert carrying 0.4 mg of dexamethasone, which is inserted into the canaliculus.[15] It is activated with moisture and subsequently releases dexamethasone to the ocular surface for up to 30 days. The carrier substrate is gradually resorbed over around 90 days, therefore manual removal of the Dextenza insert is not necessary.[15]

Outcomes

Common outcome measures for measuring inflammation in clinical studies after cataract surgery are intraocular pressure (IOP), best corrected visual acuity (BCVA), macular thickness, and anterior chamber cells/flare counts.

Subconjunctival injection

A 2019 study concluded that the use of a single injection of 5 mg subconjunctival triamcinolone acetonide (SCTA) at the end of uneventful cataract surgery is equally if not more effective compared to prolonged topical steroid use. There was no significant difference in post-op IOP, post-op cells/flare counts, or macular thickness between the SCTA group and the control group.[16]

In this study, an SCTA injection with a volume of 1 mL of triamcinolone at a concentration of 10 mg/mL was used; a 1-mL syringe with 26-gauge needle was used to withdraw 0.5 mL, which was injected under the inferior bulbar conjunctiva at the end of cataract surgery.[16]

On the contrary, a 2023 study found that dropless cataract surgery via a single injection of 5 mg SCTA increased the risk of post-op prolonged steroid response, which can lead to increased IOP after surgery during recovery.[17]

In this study, a subconjunctival triamcinolone injection with a volume of 0.3-0.5 mL of triamcinolone at a concentration of 40 mg/mL was injected approximately 5 mm posterior to the limbus at the end of cataract surgery.[17]

Steroid Volume and Concentration

In 2024, Shorstein et al. compared each of four TA (Kenalog®, Bristol-Myers-Squibb, 130 Redwood City, CA) injection groups to two topical groups.[13]

Injection groups[13]

  • TA 10 mg/mL low*
  • TA 10 mg/mL high**
  • TA 40 mg/mL low
  • TA 40 mg/mL high


*low total dose = 1.0-3.0 mg

**high total dose = 3.1-5.0 mg

Topical groups[13]

  • Topical prednisolone acetate (PA) alone
  • Topical PA and topical NSAID (either diclofenac sodium 1% or ketorolac tromethamine 0.5%)


Results[13]

  • Injection of 4 mg SCTA at a concentration of 10 mg/mL, injected in the subconjunctival space 6-8 mm inferior to the inferior limbus, was associated with lower odds of postop ME and iritis and similar odds of a postop glaucoma-related event.[13]
  • Injection of SCTA at low or high doses at a concentration of 40 mg/mL was associated with lower odds of postop ME and iritis but statistically higher odds of a postop glaucoma event.[13]
  • The less concentrated, higher volume TA 10 mg/mL high dose group covers a larger surface area and dissipates via scleral diffusion conjunctival lymphatics and blood vessels faster.[13]

Location

Injecting TA 6-8 mm inferior to the inferior limbus decreases the risk of postop inflammation due to its posterior location away from the anterior chamber. It also obscures the depot to the patient.[13]

Sub-tenon injection

A 2022 randomized control trial found that a single sub-tenon injection of 20 mg triamcinolone had no significant difference in post-op IOP, BCVA, or CFT (central foveal thickness) compared to topical 0.1% dexamethasone eye drops at the end of uncomplicated cataract surgery.[18]

Intravitreal injection

A 2021 study compared the use of 3 mg intravitreal triamcinolone acetonide (IVTA) to topical steroids in patients with uveitic cataracts and found better outcomes in the IVTA group across all measures, which included BCVA, anterior chamber inflammation, IOP, corneal endothelial cell density, and central macular thickness.[19]

A 2018 study done on glaucoma patients who underwent cataract surgery with trabecular microbypass stent insertion either with intravitreal triamcinolone-moxifloxacin-vancomycin during surgery or traditional topical antibiotics, steroids, and nonsteroidal anti-inflammatory drugs after surgery found no significant difference in IOP, cystoid macular edema (CME), infection, or retinal detachments post-surgery between the two groups.[20]

Dexycu intracameral drug delivery suspension

Dexycu has been shown to be more effective than topical steroids at decreasing inflammation after vitreoretinal surgery.[5] However, cases of iris atrophy have been reported after administration of Dexycu in uncomplicated cataract surgery.[21]

Dextenza intracanalicular insert

A 2022 study compared the use of a 0.4 mg Dextenza insert to a typical topical steroid regimen of tapering prednisolone acetate 1% (1 mg/mL) 4 times a day, 3 times a day, 2 times a day, and 1 time a day, each for 1 week, and found no significant difference in breakthrough inflammation, mean change in IOP, CME, pain, conjunctival injection, or anterior chamber reaction between the two groups.[15]

Complications

Toxic Anterior Segment Syndrome (TASS)

Toxic anterior segment syndrome (TASS) is an acute, sterile, inflammatory reaction characterized by diffuse limbus-to-limbus corneal edema due to endothelial layer damage, fibrinous reaction in the anterior chamber, and hypopyon.[22] TASS generally presents within 12-48 hours after surgery and is restricted to the anterior segment[22], unlike endophthalmitis which can cause swelling of both anterior and posterior chambers. The most common symptom is vision loss. In most cases, inflammation is resolved with intense topical steroids, but permanent vision loss can occur in severe cases.[22]

Toxic Posterior Segment Syndrome (TPSS)

Toxic posterior segment syndrome (TPSS) is a rare, serious complication after intraocular injection of compounded triamcinolone-moxifloxacin during dropless cataract surgery.[23] TPSS is a progressive toxic maculopathy that causes painless vision loss and subjective visual changes (outer retinal thinning can be seen on OCT), which usually plateau around three months after surgery.[23] Physicians and pharmacists should be aware of the drug compounding processes used in surgical products to ensure that these products do not contain any potentially toxic compounds.

Postoperative Hemorrhagic Occlusive Retinal Vasculitis (HORV)

Postoperative hemorrhagic occlusive retinal vasculitis (HORV) is another rare, serious complication that can arise after use of intracameral vancomycin during cataract surgery.[24] Intracameral vancomycin has also been associated with ischemic retinal vasculitis.[25] Like TPSS, retinal vasculitis leads to painless vision loss and poor visual outcomes despite aggressive treatments.

Supplemental topical anti-inflammatory drops may still be necessary for patients with ocular histories that put them at risk for increased inflammation after cataract surgery.

References

  1. ↑ Gower, E. W., Lindsley, K., Tulenko, S. E., Nanji, A. A., Leyngold, I., & McDonnell, P. J. (2017). Perioperative antibiotics for prevention of acute endophthalmitis after cataract surgery. The Cochrane Database of Systematic Reviews, 2(2), CD006364. https://doi.org/10.1002/14651858.CD006364.pub3
  2. ↑ Endophthalmitis Study Group, European Society of Cataract & Refractive Surgeons. Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk
  3. ↑ 3.0 3.1 3.2 3.3 Intracameral Medications Following Cataract Surgery—EyeWiki. (n.d.). Retrieved December 28, 2023, from https://eyewiki.aao.org/Intracameral_Medications_Following_Cataract_Surgery
  4. ↑ Cystoid Macular Edema—EyeWiki. (n.d.). Retrieved April 28, 2024, from https://eyewiki.org/Cystoid_Macular_Edema
  5. ↑ 5.0 5.1 5.2 Kiernan, D. F. (2020). Dexamethasone intracameral drug-delivery suspension for inflammation associated with vitreoretinal surgery. BMJ Open Ophthalmology, 5(1), e000491. https://doi.org/10.1136/bmjophth-2020-000491
  6. ↑ Guidera, A. C., Luchs, J. I., & Udell, I. J. (2001). Keratitis, ulceration, and perforation associated with topical nonsteroidal anti-inflammatory drugs. Ophthalmology, 108(5), 936–944. https://doi.org/10.1016/s0161-6420(00)00538-8
  7. ↑ Yamamoto, Y., Komatsu, T., Koura, Y., Nishino, K., Fukushima, A., & Ueno, H. (2008). Intraocular pressure elevation after intravitreal or posterior sub-Tenon triamcinolone acetonide injection. Canadian Journal of Ophthalmology, 43(1), 42–47. https://doi.org/10.3129/i07-186
  8. ↑ Athanasiadis, Y., Nithyanandrajah, G. A. L., Kumar, B., & Sharma, A. (2009). Reversal of steroid induced raised intraocular pressure following removal of subconjunctival triamcinolone for cataract surgery. Contact Lens and Anterior Eye, 32(3), 143–144. https://doi.org/10.1016/j.clae.2008.08.004
  9. ↑ Choi, W., Bae, H. W., Choi, E. Y., Kim, M., Kim, E. W., Kim, C. Y., Kim, M., & Seong, G. J. (2020). Age as a risk factor for steroid-induced ocular hypertension in the non-paediatric population. British Journal of Ophthalmology, 104(10), 1423–1429. https://doi.org/10.1136/bjophthalmol-2019-314559
  10. ↑ Chang, D. F., Tan, J. J., & Tripodis, Y. (2011a). Risk factors for steroid response among cataract patients. Journal of Cataract and Refractive Surgery, 37(4), 675–681. https://doi.org/10.1016/j.jcrs.2010.10.051
  11. ↑ Stanley, R. G. (2008). Chapter 25—Ocular clinical pharmacology. In J. E. Maddison, S. W. Page, & D. B. Church (Eds.), Small Animal Clinical Pharmacology (Second Edition) (pp. 557–573). W.B. Saunders. https://doi.org/10.1016/B978-070202858-8.50027-0
  12. ↑ Ophthalmologists & Retina Specialists of Vitreous Retina Macula Consultants of New York. (n.d.). Subtenon Injection. Vitreous Retina Macula Consultants of New York. Retrieved January 14, 2024, from https://www.vrmny.com/procedures/subtenon-injection/
  13. ↑ 13.0 13.1 13.2 13.3 13.4 13.5 13.6 13.7 13.8 Shorstein, N. H., McCabe, S. E., Alavi, M., Kwan, M. L., & Chandra, N. S. (2024). Triamcinolone Acetonide Subconjunctival Injection as Stand-alone Inflammation Prophylaxis after Phacoemulsification Cataract Surgery. Ophthalmology, 0(0). https://doi.org/10.1016/j.ophtha.2024.03.025
  14. ↑ Scott, I. U. & Flynn Jr., H.W. (2015). An Update on the Intravitreal Injection Procedure. Retrieved January 14, 2024, from http://www.retina-specialist.com/article/an-update-on-the-intravitreal-injection-procedure
  15. ↑ 15.0 15.1 15.2 Lu, A. Q., Rizk, M., O’Rourke, T., Goodling, K., Lehman, E., Scott, I. U., & Pantanelli, S. M. (2022). Safety and efficacy of topical vs intracanalicular corticosteroids for the prevention of postoperative inflammation after cataract surgery. Journal of Cataract and Refractive Surgery, 48(11), 1242–1247. https://doi.org/10.1097/j.jcrs.0000000000000963
  16. ↑ 16.0 16.1 Reddy, J. K., Chaitanya, V., Shah, N., Guduru, V. P., Khan, S., & Kuttupalayam, S. (2019). Safety & efficacy of single subconjunctival triamcinolone 5 mg depot vs topical loteprednol post cataract surgery: Less drop cataract surgery. International Journal of Ophthalmology, 12(5), 774–778. https://doi.org/10.18240/ijo.2019.05.11
  17. ↑ 17.0 17.1 Wu, A. M., Pitts, K. M., Pineda, R., Chen, S. H., Wang, M., Johnson, G., Shen, L. Q., & Margeta, M. A. (2023). Steroid Response Following Dropless Cataract Surgery Using Subconjunctival Triamcinolone. Clinical Ophthalmology (Auckland, N.Z.), 17, 2803–2814. https://doi.org/10.2147/OPTH.S426200
  18. ↑ Choopong, P., Taetrongchit, N., Boonsopon, S., Nimkarn, A., Srisukkosalin, K., Chonpimai, P., Nujoi, W., Maneephagaphun, K., Panyayingyong, N., & Tesavibul, N. (2022). Efficacy of subtenon 20-mg triamcinolone injection versus 0.1% dexamethasone eye drops for controlling inflammation after phacoemulsification: A randomized controlled trial. Scientific Reports, 12(1), Article 1. https://doi.org/10.1038/s41598-022-20522-y
  19. ↑ Ren, Y., Du, S., Zheng, D., Shi, Y., Pan, L., & Yan, H. (2021). Intraoperative intravitreal triamcinolone acetonide injection for prevention of postoperative inflammation and complications after phacoemulsification in patients with uveitic cataract. BMC Ophthalmology, 21(1), 245. https://doi.org/10.1186/s12886-021-02017-y
  20. ↑ Kindle, T., Ferguson, T., Ibach, M., Greenwood, M., Schweitzer, J., Swan, R., Sudhagoni, R. G., & Berdahl, J. P. (2018). Safety and efficacy of intravitreal injection of steroid and antibiotics in the setting of cataract surgery and trabecular microbypass stent. Journal of Cataract and Refractive Surgery, 44(1), 56–62. https://doi.org/10.1016/j.jcrs.2017.10.040
  21. ↑ Bergman, Z., Thompson, R., Malouf, A., & Swamy, R. (2022). Iris Atrophy After Administration of Intracameral Dexycu in Routine Cataract Surgery: A Case Series. Eye & Contact Lens, 48(4), 185–187. https://doi.org/10.1097/ICL.0000000000000873
  22. ↑ 22.0 22.1 22.2 Cetinkaya, S., Dadaci, Z., Aksoy, H., Acir, N. O., Yener, H. I., & Kadioglu, E. (2014). Toxic anterior-segment syndrome (TASS). Clinical Ophthalmology (Auckland, N.Z.), 8, 2065–2069. https://doi.org/10.2147/OPTH.S71541
  23. ↑ 23.0 23.1 Patel, K.G. & Abbey, A.M. (2022). A Toxic Side Effect of Dropless Surgery. Retina Today; Bryn Mawr Communications. Retrieved January 14, 2024, from https://retinatoday.com/articles/2022-nov-dec/a-toxic-side-effect-of-dropless-surgery
  24. ↑ Witkin, A. J., Shah, A. R., Engstrom, R. E., Kron-Gray, M. M., Baumal, C. R., Johnson, M. W., Witkin, D. I., Leung, J., Albini, T. A., Moshfeghi, A. A., Batlle, I. R., Sobrin, L., & Eliott, D. (2015). Postoperative Hemorrhagic Occlusive Retinal Vasculitis: Expanding the Clinical Spectrum and Possible Association with Vancomycin. Ophthalmology, 122(7), 1438–1451. https://doi.org/10.1016/j.ophtha.2015.03.016
  25. ↑ Lenci, L. T., Chin, E. K., Carter, C., Russell, S. R., & Almeida, D. R. P. (2015). Ischemic Retinal Vasculitis Associated with Cataract Surgery and Intracameral Vancomycin. Case Reports in Ophthalmological Medicine, 2015, 683194. https://doi.org/10.1155/2015/683194
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