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You are here: Home / Cataracts / Advantages plentiful with dropless cataract surgery

Advantages plentiful with dropless cataract surgery

May 01, 2014 Healio News

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

Issue: May 25, 2014 By James S. Lewis, MD

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

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. 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.

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.

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; 215-886-9090; fax: 887-245-3560; email: jslewis@jameslewismd.com.
  • Disclosure: Lewis is a consultant to Imprimis Pharmaceuticals.

Filed Under: Cataracts, dropless cataract surgery

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Our practice will start seeing patients again on M Our practice will start seeing patients again on Monday, May 11th in full compliance with all local, state, and federal guidelines. This includes masks, social distancing, and the disinfection of all common surfaces. Elective surgeries are also being rescheduled. Care will be taken to avoid office congestion and minimize exposure to COVID-19.

We require: ➡️ You do not have fever, chills, shaking, muscle pain, headache, sore throat, or a loss of taste or smell ➡️ You have not had exposure to anyone with a flu-like illness within the past two weeks ➡️ You wear a mask or equivalent facial covering over both your nose and mouth ➡️ You agree to maintain social distancing ➡️ You avoid touching your eyes, nose, mouth, and face ➡️ You enter the office alone if possible

Expect to hear from our staff shortly. You may contact us at your convenience from links at jameslewismd.com
Chorioretinal folds are a known finding following Chorioretinal folds are a known finding following penetrating glaucoma surgery, as in these two cases who underwent Ahmed valve tube shunt placement. Prevalence is estimated between 10-50% of incisional glaucoma surgeries.

Pic 1.) several linear chorioretinal folds throughout the posterior pole. Intraocular pressure was 4mmHg at the time of this photo. The fundus and visual acuity returned to baseline within a week as IOP leveled at 10mmHg.
Pic 2.) Small choroidal folds can be seen distributed temporal to the macula. This image also demonstrates a large hemorrhage consistent with ocular decompression retinopathy.
Pic 3.) shows complete resolution of the choroidal folds and hemorrhage after 4 weeks in patient 2.

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Inflammation of the anterior chamber can create fi Inflammation of the anterior chamber can create fibrin plaques that are readily seen within the pupil. The second and third images demonstrate an almost completely occluded pupil with synechia formation. The fourth image demonstrates an ultrasound biomicroscopy image of a patient in angle closure following complete pupil occlusion from fibrin (blue arrow). Aggressive corticosteroid therapy can ‘melt’ the fibrin and cycloplegics can mechanically disrupt it. Nd:YAG laser can also instantly disrupt total occlusion.

#ophthalmology #ophthalmologist #ophthalmictech #ophthalmologyresident #ophthalmicphotography #ophthalmicsurgery #cornea #corneasurgery #eyesurgeon #eyesurgery #eye #oculardisease #optometry #ocularinflammation #optometrystudent #optom #sunyoptometry #osuopt #salusuniversity
Descemet stripping endothelial keratoplasty (DSEK) Descemet stripping endothelial keratoplasty (DSEK) is a corneal transplant procedure that replaces only the innermost cells of the cornea. It is readily combined with cataract surgery to improve refractive outcomes. This is a one day post operative visit of a DSEK showing faint edema and remaining air bubble. The air bubble will typically dissolve over the first 48-72 hours.

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Ocular surface disease is a complex state that rep Ocular surface disease is a complex state that represents a poorly performing pre-corneal tear film. It can frustrate many patients and can be challenging for clinicians. No two cases are alike.

In this case, a young patient without evidence of desiccation or inflammation had persistent physical symptoms. Biomicroscopy revealed clear lid margins, no conjunctival injection, and no corneal epitheliopathy. Meibography (imaging the meibomian glands) provides insight into the cause. A previous course of oral medication that acts on sebaceous glands has likely impacted his meibomian glands as well. The gland dropout is easily seen as truncation and atrophy. The final video demonstrates a noninvasive tear-breakup time where the red squares are regions with early loss of tear film stability.

#ophthalmology #ophthalmologist #ophthalmictech #ophthalmologyresident #ophthalmicphotography #ophthalmicsurgery #cornea #corneasurgery #eyesurgeon #eyesurgery #dryeye #ocularsurfacedisease #OSD #eye #oculardisease #optometry #optometrystudent #optom #sunyoptometry #osuopt #salusuniversity
Iris cysts are benign. If suspected, they should b Iris cysts are benign. If suspected, they should be imaged with ultrasound biomicroscopy (UBM) to confirm the diagnosis and rule out other causes of iris elevation.
#ophthalmology #ophthalmologist #ophthalmictech #ophthalmologyresident #ophthalmicphotography #ophthalmicsurgery #cornea #corneasurgery #eyesurgeon #eyesurgery #ubm #eye #oculardisease #optometry #optometrystudent #optom #sunyoptometry #osuopt #salusuniversity

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