Drop-Free Approaches for Cataract Surgery

Neal H. Shorstein; William G. Myers


Curr Opin Ophthalmol. 2020;31(1):67-73. 

In This Article

Drop-free Strategies

The simplest approach combines intracameral antibiotic injection with subconjunctival injection of triamcinolone acetonide, both of which have supporting evidence in the literature. Newer technologies, recently approved and on the horizon, are also described below.

Intracameral Antibiotic and Subconjunctival Steroid

Combining intracameral antibiotic injection with subconjunctival injection of 4 mg triamcinolone had similar infection and inflammation rates in one prospective study compared with drops.[65] A second prospective study showed less macular thickening on OCT with triamcinolone 20 mg injection and similar visual acuity compared with drops.[66]

Intravitreal Injection

Another option for injection of antibiotic and antiinflammatory drug is via a transzonular or pars plana approach.[69] One study showed a higher breakthrough iritis rate with injection compared to drops.[70] Other concerns with this approach include the lack of comparative studies showing safety and effectiveness and an unknown long-term risk of damage to the zonular matrix and the retina. There is also a lack of data describing the pharmacokinetics of either antibiotic or corticosteroid in the vitreous space for the prevention of endophthalmitis. A recent report of four endophthalmitis cases with this approach may support additional concern for this modality.[71]

Developing Technologies

A suspension of dexamethasone (Dexycu, Eyepoint Pharmaceuticals, Watertown, USA) for intracameral injection posterior to the iris was approved by the FDA in 2018. The new agent was shown to be better than placebo for clearance of anterior chamber cell and flare.[72] The injectable suspension was comparable to prednisolone drops in anterior chamber clearing but with a slightly higher proportion of eyes with corneal edema and increased IOP.[73]

A dexamethasone impregnated canalicular plug (Dextenza, Ocular Therapeutix, Bedford, USA) was also approved in 2018. Phase III data showed superiority over placebo for pain and postop inflammation.[74]

Technologies currently in development include intraocular lens (IOL) presoaking in antibiotic and NSAID.[75,76] Adding an intracameral antibiotic injection at the conclusion of surgery to the placement of a presoaked lens may provide a high initial concentration of drug from the injection along with a sustained level of drug in the days following surgery[77] from the IOL.