Advantages plentiful with dropless cataract surgery

The technique is effective, saves time and money, and has good results.

Ophthalmic surgeons can expect their cataract patients to complain about the high cost of postop medications. Staff time is lost on brand vs. generic discussions, insurance coverage concerns, frequency and duration of treatment questions, and renewals. Tech resources are devoured in determining exactly which drugs were received and how they are being used because these rarely coincide with the scripts written.

Once Jeff Liegner, MD, of Sparta, N.J., described his technique and special formulation of triamcinolone, moxifloxacin and vancomycin (TriMoxiVanc), I gave it a try. I will never go back to the time sink of postop poly-pharmacopoeia.

Approximately 3 months and 500 patients later, the patients, staff and surgeon are happier with dropless cataract surgery. No more emergency pages for medication clarification, no more requests for a suitable generic, no more time wasted looking through a patient’s possessions to determine the actual name of the drops they are using, and no more explaining that we do not have free samples to give.

James S. Lewis, MD

James S. Lewis

I have put video of my first cases on the Internet, and while it has not gone viral, there is considerable interest. I believe it is only a matter of time before patients insist on dropless cataract surgery in the same way they demand custom or bladeless LASIK. In fact, Imprimis Pharmaceuticals, the company that acquired the intellectual property in August 2013 for the special patent-pending blend of antibiotics and steroids, has launched a “GoDropless” campaign.

Learning the technique

Jim Gills, Doug Koch, Stewart Galloway and others pioneered the trail, and I am very happy to follow. There is a very short learning curve to this technique. Liegner suggests walking the cannula out beyond the capsule, tapping it gently as you proceed. I find it best to visualize the anatomy while the eye is oriented orthogonally. One caveat is that aiming too far out will generate some mild patient discomfort and some annoying but self-limited bleeding. I find it helpful to make certain the patient is cooperative before this maneuver. It is important to make sure the cannula is well secured, there are no bubbles in the syringe and you have more than 0.2 cc of medication. In fact, I prefer to use the same amount in the syringe each time.

The surgeon must be comfortable watching a perfect red reflex become obscured. This cloud dissipates quickly; few patients will notice it and even fewer will complain. There were only a few reports of floaters or clouds postoperatively, and most patients were comforted to know that it was “just the medicine.” The first thing you notice on postoperative day 1 is that there is an unexpected pause at the end of the examination. In the same way LASIK patients reach for their glasses for the first few weeks after surgery, you will have an instinctual desire to remind the patient to use drops. This awkwardness passes easily.

My staff and I made absolutely no effort to avoid adding a steroid if needed. Any patient who had cystoid macular edema in the other eye or those with any degree of corneal edema got a steroid on day 1. Any patients with even modest complaints of photophobia, redness or foreign body sensation, as well as those with ciliary flush, were treated. I added steroids to an uncomplicated post-graft cataract but did not use steroids in a few cases with planned vitrectomies and sutured posterior chamber IOLs.

After IOL implantation, while dispersive viscoelastic fills the anterior chamber, a 27-gauge Knolle cannula on a 1 cc tuberculin syringe is inserted behind the iris and above the peripheral anterior capsule.
Once the cannula is advanced through the zonules, 0.2 cc of TriMoxiVanc is injected into the retrozonular space of Petit.
A slow but steady motion of 2 to 4 seconds is required.
During this time, most of the viscoelastic exits the eye.
Residual viscoelastic is removed through irrigation and aspiration, followed by stromal hydration and limbal relaxing incisions as needed.
Residual viscoelastic is removed through irrigation and aspiration, followed by stromal hydration and limbal relaxing incisions as needed.

After IOL implantation, while dispersive viscoelastic fills the anterior chamber, a 27-gauge Knolle cannula on a 1 cc tuberculin syringe is inserted behind the iris and above the peripheral anterior capsule. Once the cannula is advanced through the zonules, 0.2 cc of TriMoxiVanc is injected into the retrozonular space of Petit. A slow but steady motion of 2 to 4 seconds is required. During this time, most of the viscoelastic exits the eye. Residual viscoelastic is removed through irrigation and aspiration, followed by stromal hydration and limbal relaxing incisions as needed. This technique is applicable to femtosecond laser-assisted cataract surgery as well as conventional phacoemulsification. The antibiotic-steroid combination is seen behind the implant, obscuring the red reflex. Eighty-six percent of my first 500 patients required no postoperative drops. Pressure spikes, vitreous loss, bleeding and visual complaints are rare, transient or entirely absent.

Images: Lewis JS

Patient response

More patients with combined cataract-AquaFlow (STAAR Surgical), as well as those with a combined cataract-Ahmed valve surgery, complained of tenderness. They accounted for eight of the 12 patients who needed postop steroid.

None of the eyes were “hot”; instead, they responded to a twice-daily steroid. No NSAIDs were used.

B-scan (Quantel Medical) is performed immediately after the surgical drape was removed, approximately 1 minute after TriMoxiVanc injection.

B-scan (Quantel Medical) is performed immediately after the surgical drape was removed, approximately 1 minute after TriMoxiVanc injection.

A second patient is imaged after transzonular placement of the drug. The injected medication appears to follow Cloquet’s canal and accumulates immediately anterior to the macula.

A second patient is imaged after transzonular placement of the drug. The injected medication appears to follow Cloquet’s canal and accumulates immediately anterior to the macula.

Gonioprism shows placement of the cannula peripheral to the capsule and insinuated in the zonules. Medication is injected behind the posterior capsule with no disturbance of the posterior chamber IOL.

Gonioprism shows placement of the cannula peripheral to the capsule and insinuated in the zonules. Medication is injected behind the posterior capsule with no disturbance of the posterior chamber IOL.

My older patients with chronic diseases, especially those with diabetes and hypertension, fared as well as my healthy and often younger patients. In fact, the postoperative slit lamp appearance was unremarkable. Clinic hours ended earlier; there was less talk about drops and more conversation about how much they enjoyed the experience.

Because I went dropless all at once, a fair number of patients had their first eye done with postoperative topical medications. They all had purchased drops for their second eye as a precaution. Virtually all of these patients claimed their experience without drops and their visual function were superior in the second surgery. Most of them, however, complained that they purchased medications they did not need.

Although this experience is anecdotal at best, and any conclusions regarding safety and effectiveness must wait for those willing to perform a masked prospective study, I am comfortable using this technique from this point forward.

Why put antibiotics on the corneal surface when the infectious agents are in the vitreous? Why put topical steroids and somewhat toxic NSAIDs on the surface when inflammation is on the inside?

If endophthalmitis occurs after cataract surgery, we ask the retina folks to put vancomycin and gentamicin in the vitreous. If chronic CME arises, we ask them to inject steroid in the vitreous. We know that these maneuvers are safe and effective.

In my opinion, transciliary instillation of steroids and antibiotics as prophylaxis will become the standard of care. Dropless cataract surgery is effective, timesaving, hassle-free, convenient and easy. This is premium cataract surgery for all patients.

  • James S. Lewis, MD, can be reached at 8380 Old York Road, Suite 110 A, Elkins Park, PA 19027; 800-700-3937; fax: 215-893-8779; email: jslewis@jameslewismd.com.
  • Disclosure: Lewis is a consultant to Imprimis Pharmaceuticals.

Ophthalmic surgeons can expect their cataract patients to complain about the high cost of postop medications. Staff time is lost on brand vs. generic discussions, insurance coverage concerns, frequency and duration of treatment questions, and renewals. Tech resources are devoured in determining exactly which drugs were received and how they are being used because these rarely coincide with the scripts written.

Once Jeff Liegner, MD, of Sparta, N.J., described his technique and special formulation of triamcinolone, moxifloxacin and vancomycin (TriMoxiVanc), I gave it a try. I will never go back to the time sink of postop poly-pharmacopoeia.

Approximately 3 months and 500 patients later, the patients, staff and surgeon are happier with dropless cataract surgery. No more emergency pages for medication clarification, no more requests for a suitable generic, no more time wasted looking through a patient’s possessions to determine the actual name of the drops they are using, and no more explaining that we do not have free samples to give.

James S. Lewis, MD

James S. Lewis

I have put video of my first cases on the Internet, and while it has not gone viral, there is considerable interest. I believe it is only a matter of time before patients insist on dropless cataract surgery in the same way they demand custom or bladeless LASIK. In fact, Imprimis Pharmaceuticals, the company that acquired the intellectual property in August 2013 for the special patent-pending blend of antibiotics and steroids, has launched a “GoDropless” campaign.

Learning the technique

Jim Gills, Doug Koch, Stewart Galloway and others pioneered the trail, and I am very happy to follow. There is a very short learning curve to this technique. Liegner suggests walking the cannula out beyond the capsule, tapping it gently as you proceed. I find it best to visualize the anatomy while the eye is oriented orthogonally. One caveat is that aiming too far out will generate some mild patient discomfort and some annoying but self-limited bleeding. I find it helpful to make certain the patient is cooperative before this maneuver. It is important to make sure the cannula is well secured, there are no bubbles in the syringe and you have more than 0.2 cc of medication. In fact, I prefer to use the same amount in the syringe each time.

The surgeon must be comfortable watching a perfect red reflex become obscured. This cloud dissipates quickly; few patients will notice it and even fewer will complain. There were only a few reports of floaters or clouds postoperatively, and most patients were comforted to know that it was “just the medicine.” The first thing you notice on postoperative day 1 is that there is an unexpected pause at the end of the examination. In the same way LASIK patients reach for their glasses for the first few weeks after surgery, you will have an instinctual desire to remind the patient to use drops. This awkwardness passes easily.

My staff and I made absolutely no effort to avoid adding a steroid if needed. Any patient who had cystoid macular edema in the other eye or those with any degree of corneal edema got a steroid on day 1. Any patients with even modest complaints of photophobia, redness or foreign body sensation, as well as those with ciliary flush, were treated. I added steroids to an uncomplicated post-graft cataract but did not use steroids in a few cases with planned vitrectomies and sutured posterior chamber IOLs.

After IOL implantation, while dispersive viscoelastic fills the anterior chamber, a 27-gauge Knolle cannula on a 1 cc tuberculin syringe is inserted behind the iris and above the peripheral anterior capsule.
Once the cannula is advanced through the zonules, 0.2 cc of TriMoxiVanc is injected into the retrozonular space of Petit.
A slow but steady motion of 2 to 4 seconds is required.
During this time, most of the viscoelastic exits the eye.
Residual viscoelastic is removed through irrigation and aspiration, followed by stromal hydration and limbal relaxing incisions as needed.
Residual viscoelastic is removed through irrigation and aspiration, followed by stromal hydration and limbal relaxing incisions as needed.

After IOL implantation, while dispersive viscoelastic fills the anterior chamber, a 27-gauge Knolle cannula on a 1 cc tuberculin syringe is inserted behind the iris and above the peripheral anterior capsule. Once the cannula is advanced through the zonules, 0.2 cc of TriMoxiVanc is injected into the retrozonular space of Petit. A slow but steady motion of 2 to 4 seconds is required. During this time, most of the viscoelastic exits the eye. Residual viscoelastic is removed through irrigation and aspiration, followed by stromal hydration and limbal relaxing incisions as needed. This technique is applicable to femtosecond laser-assisted cataract surgery as well as conventional phacoemulsification. The antibiotic-steroid combination is seen behind the implant, obscuring the red reflex. Eighty-six percent of my first 500 patients required no postoperative drops. Pressure spikes, vitreous loss, bleeding and visual complaints are rare, transient or entirely absent.

Images: Lewis JS

PAGE BREAK

Patient response

More patients with combined cataract-AquaFlow (STAAR Surgical), as well as those with a combined cataract-Ahmed valve surgery, complained of tenderness. They accounted for eight of the 12 patients who needed postop steroid.

None of the eyes were “hot”; instead, they responded to a twice-daily steroid. No NSAIDs were used.

B-scan (Quantel Medical) is performed immediately after the surgical drape was removed, approximately 1 minute after TriMoxiVanc injection.

B-scan (Quantel Medical) is performed immediately after the surgical drape was removed, approximately 1 minute after TriMoxiVanc injection.

A second patient is imaged after transzonular placement of the drug. The injected medication appears to follow Cloquet’s canal and accumulates immediately anterior to the macula.

A second patient is imaged after transzonular placement of the drug. The injected medication appears to follow Cloquet’s canal and accumulates immediately anterior to the macula.

Gonioprism shows placement of the cannula peripheral to the capsule and insinuated in the zonules. Medication is injected behind the posterior capsule with no disturbance of the posterior chamber IOL.

Gonioprism shows placement of the cannula peripheral to the capsule and insinuated in the zonules. Medication is injected behind the posterior capsule with no disturbance of the posterior chamber IOL.

My older patients with chronic diseases, especially those with diabetes and hypertension, fared as well as my healthy and often younger patients. In fact, the postoperative slit lamp appearance was unremarkable. Clinic hours ended earlier; there was less talk about drops and more conversation about how much they enjoyed the experience.

Because I went dropless all at once, a fair number of patients had their first eye done with postoperative topical medications. They all had purchased drops for their second eye as a precaution. Virtually all of these patients claimed their experience without drops and their visual function were superior in the second surgery. Most of them, however, complained that they purchased medications they did not need.

Although this experience is anecdotal at best, and any conclusions regarding safety and effectiveness must wait for those willing to perform a masked prospective study, I am comfortable using this technique from this point forward.

Why put antibiotics on the corneal surface when the infectious agents are in the vitreous? Why put topical steroids and somewhat toxic NSAIDs on the surface when inflammation is on the inside?

If endophthalmitis occurs after cataract surgery, we ask the retina folks to put vancomycin and gentamicin in the vitreous. If chronic CME arises, we ask them to inject steroid in the vitreous. We know that these maneuvers are safe and effective.

In my opinion, transciliary instillation of steroids and antibiotics as prophylaxis will become the standard of care. Dropless cataract surgery is effective, timesaving, hassle-free, convenient and easy. This is premium cataract surgery for all patients.

  • James S. Lewis, MD, can be reached at 8380 Old York Road, Suite 110 A, Elkins Park, PA 19027; 800-700-3937; fax: 215-893-8779; email: jslewis@jameslewismd.com.
  • Disclosure: Lewis is a consultant to Imprimis Pharmaceuticals.