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Christensen MT, Davenport CS, Yin HY, Thompson AC, Walter KA. Dropless Cataract Surgery: The Effect of Intracameral Phenylephrine/Ketorolac Infusion as a Single Agent on Postoperative Outcomes. Cureus 2024; 16:e62866. [PMID: 39040772 PMCID: PMC11260910 DOI: 10.7759/cureus.62866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2024] [Indexed: 07/24/2024] Open
Abstract
Objective The objective of this study was to assess the feasibility of using an intracameral phenylephrine/ketorolac infusion during cataract surgery as a single agent to prevent postoperative pain, inflammation, and other complications. Methods A prospective, single-group feasibility study was conducted in which phenylephrine/ketorolac infusion was administered during cataract surgery and no perioperative topical drops were initially prescribed. Patients underwent optical coherence tomography, corrected distance visual acuity testing, and slit lamp biomicroscopy examination at perioperative visits, during which they also reported symptoms of pain, irritation, and/or photophobia. A goal adverse event (AE) rate was set at ≤5.0%. Results A total of 94 eyes (60 patients) were included in this study. The AE rate was 13.8% (13/94 eyes) with pain/irritation in eight eyes, cystoid macular edema (CME) in three eyes, and corneal edema in three eyes. Conclusions Based on an AE rate goal of ≤5.0%, using intraoperative, intracameral phenylephrine/ketorolac alone was not deemed a feasible alternative to current postoperative eye drop regimens in our clinical setting. However, a 13.8% AE rate is comparable to the rates of postoperative CME, corneal edema, pain, and irritation in the published literature. Thus, more research is needed to truly define this approach as inferior or non-inferior to the current standard of care.
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Affiliation(s)
| | - Connor S Davenport
- Surgical Ophthalmology, Eye Surgeons Associates, Bettendorf, USA
- Surgical Ophthalmology, Wake Forest School of Medicine, Winston-Salem, USA
| | - Han Y Yin
- Surgical Ophthalmology, Milan Eye Center, Cumming, USA
- Surgical Ophthalmology, Wake Forest School of Medicine, Winston-Salem, USA
| | - Atalie C Thompson
- Surgical Ophthalmology/Geriatrics, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, USA
| | - Keith A Walter
- Surgical Ophthalmology, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, USA
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Gautam M, Gupta R, Singh P, Verma V, Verma S, Mittal P, Karkhur S, Sampath A, Mohan RR, Sharma B. Intracameral Drug Delivery: A Review of Agents, Indications, and Outcomes. J Ocul Pharmacol Ther 2023; 39:102-116. [PMID: 36757304 DOI: 10.1089/jop.2022.0144] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
Abstract
An intracameral (IC) injection directly delivers the drug into the anterior chamber of the eye. This targeted drug delivery technique overcomes the ocular barriers and offers a high therapeutic concentration of medication at the desired site and consequently better clinical outcomes. IC drug delivery is a safe and effective modality with many advantages over topical delivery. These include excellent bioavailability, reduced systemic risk, and minimal ocular toxicity. Agents delivered via IC injection have shown promising results against infection, inflammation, ocular hypertension, and neovascularization. Current literature shows that IC antibiotics, including cefuroxime, vancomycin, and moxifloxacin, are routinely used for prophylaxis of endophthalmitis. Other drugs available for IC use are steroids, anesthetics, mydriatics, miotics, antivascular endothelial growth factor, antiglaucoma, and alkylating agents. Introduction of sustained-release devices containing dexamethasone or Bimatoprost in anterior chamber via IC route has the potential in treating ocular inflammation and raised intraocular pressure. The complications such as hemorrhagic occlusive retinal vasculitis and toxic anterior segment syndrome have been documented with IC prophylaxis but are rare. In this review, we provide an overview of available IC drugs, their pharmacokinetics, the spectrum of activity, dosage and preparation, prophylactic and therapeutic usage, clinical efficacy, and safety profiles.
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Affiliation(s)
- Megha Gautam
- Department of Ophthalmology, All India Institute of Medical Sciences, Bhopal, India
| | - Rituka Gupta
- Department of Ophthalmology, All India Institute of Medical Sciences, Bhopal, India
| | - Priti Singh
- Department of Ophthalmology, All India Institute of Medical Sciences, Bhopal, India
| | - Vidhya Verma
- Department of Ophthalmology, All India Institute of Medical Sciences, Bhopal, India
| | - Sunil Verma
- Department of Ophthalmology, All India Institute of Medical Sciences, Bhopal, India
| | - Parul Mittal
- Department of Ophthalmology, All India Institute of Medical Sciences, Bhopal, India
| | - Samendra Karkhur
- Department of Ophthalmology, All India Institute of Medical Sciences, Bhopal, India
| | - Ananyan Sampath
- Department of Ophthalmology, All India Institute of Medical Sciences, Bhopal, India
| | - Rajiv R Mohan
- Department of Ophthalmology and Molecular Medicine, University of Missouri, Columbia, Missouri, USA
| | - Bhavana Sharma
- Department of Ophthalmology, All India Institute of Medical Sciences, Bhopal, India
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Visco DM. Comparison of postcataract surgery anti-inflammatory regimens on the incidence of cystoid macular edema, iritis, pain, and photophobia. J Cataract Refract Surg 2023; 49:44-49. [PMID: 35862832 DOI: 10.1097/j.jcrs.0000000000001022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 07/19/2022] [Indexed: 12/31/2022]
Abstract
PURPOSE To compare postcataract surgery anti-inflammatory regimens of intracanalicular dexamethasone insert and topical bromfenac on the incidence of cystoid macular edema (CME), iritis, pain, and photophobia. SETTING Eyes of York Cataract & Laser Center, York, Pennsylvania. DESIGN Retrospective chart review. METHODS Case records of 647 consecutive patients (1001 eyes) who underwent cataract surgery and received dexamethasone intracanalicular insert 0.4 mg (Group 1; 482 eyes) or topical nonsteroidal anti-inflammatory drug (NSAID) (bromfenac 0.075% 2 times a day) for 4 weeks postoperatively (Group 2; 519 eyes) were included. Both groups received intracameral moxifloxacin and phenylephrine/ketorolac. Patients with prior CME, vitreomacular traction, combined cataract/glaucoma surgery, and medication protocols different from those examined in this study were excluded. RESULTS Compared with the dexamethasone insert group, the topical NSAID group had a significantly lower incidence of CME (0.4% [2/519] vs 3.9% [19/482], P < .001) and photophobia (1.9% [10/519] vs 4.8% [23/482], P = .012). The incidence of breakthrough iritis (3.5% [18/519] vs 5.6% [27/482], P = .104) and pain also trended lower (4.0% [21/519] vs 5.4% [26/482], P = .314) in the topical NSAID group. CONCLUSIONS Topical NSAIDs were found to be more effective in controlling CME, pain, iritis, and photophobia after cataract surgery compared with the intracanalicular dexamethasone insert in the presence of intracameral phenylephrine/ketorolac.
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Affiliation(s)
- Denise M Visco
- From the Eyes of York Cataract & Laser Center, York, Pennsylvania
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Ishiguro N, Horiguchi H, Katagiri S, Shiba T, Nakano T. Correlation between higher-order aberration and photophobia after cataract surgery. PLoS One 2022; 17:e0274705. [PMID: 36107829 PMCID: PMC9477362 DOI: 10.1371/journal.pone.0274705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 09/01/2022] [Indexed: 11/19/2022] Open
Abstract
Cataract surgery impinges on the spatial properties and wavelength distribution of retinal images, which changes the degree of light-induced visual discomfort/photophobia. However, no study has analyzed the alteration in photophobia before and after cataract surgery or the association between retinal spatial property and photophobia. Here, we measured the higher-order aberrations (HOAs) of the entire eye and the subjective photophobia score. This study investigated 71 eyes in 71 patients who received conventional cataract surgery. Scaling of photophobia was based on the following grading system: when the patient is outdoor on a sunny day, score of 0 and 10 points were assigned to the absence of photophobia and the presence of severe photophobia prevents eye-opening, respectively. We decomposed wavefront errors using Zernike polynomials for a 3-mm pupil diameter and analyzed the association between photophobia scores and HOAs with Spearman’s rank sum correlation (rs). We classified patients into two groups: photophobia (PP) unconcerned included patients who selected 0 both preoperatively or postoperatively and PP concerned included the remaining patients. After cataract surgery, photophobia scores increased, remained unchanged (stable), and decreased in 3, 41, and 27 cases, respectively. In the stable group, 35 of 41 cases belonged to PP unconcerned. In PP concerned, there were significant correlations between photophobia score and postoperative root-mean-square values of total HOAs (rs = 0.52, p = 0.002), total coma (rs = 0.52, p = 0.002), total trefoil (rs = 0.47, p = 0.006), and third-order group (rs = 0.53, p = 0.002). In contrast, there was no significant correlation between photophobia scores and preoperative HOAs. Our results suggest that the spatial properties of retinal image modified by HOAs may affect the degree of photophobia. Scattering light due to cataracts could contribute to photophobia more than HOAs, which may mask the effect of HOAs for photophobia preoperatively.
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Affiliation(s)
- Naoko Ishiguro
- Department of Ophthalmology, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiroshi Horiguchi
- Department of Ophthalmology, The Jikei University School of Medicine, Tokyo, Japan
- * E-mail:
| | - Satoshi Katagiri
- Department of Ophthalmology, The Jikei University School of Medicine, Tokyo, Japan
| | | | - Tadashi Nakano
- Department of Ophthalmology, The Jikei University School of Medicine, Tokyo, Japan
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Abstract
PURPOSE OF REVIEW Given the epidemiology and demographic trends of diabetes mellitus and cataracts, ophthalmologists are likely to encounter patients with both comorbidities at an increasing frequency. Patients with diabetes represent a higher risk population than healthy patients for cataract surgery. In this review, we discuss key risks and risk-mitigation practices when performing cataract surgery on these patients. RECENT FINDINGS Patients with diabetes continue to represent a high-risk surgical population: Nagar et al. suggest a dose-dependent relationship may exist between number of intravitreal injections and likelihood of posterior capsular rupture. However, novel treatments are improving outcomes for patients with diabetes. Several studies have reported intracameral phenylephrine/ketorolac may reduce the incidence of post-operative cystoid macular edema while others have discussed the efficacy of pre-treatment and post-treatment with intravitreal bevacizumab on improving cataract surgery outcomes in patients with diabetic retinopathy. Pre-operatively, ophthalmologists should perform an enhanced evaluation, consider timing and lens selection decisions, and complete any appropriate pre-operative treatment. Peri-operatively, surgeons should be aware of pupillary dilation adjustments, combination surgery options, and potential complications. Post-operatively, clinicians should address pseudophakic cystoid macular edema, diabetic macular edema, diabetic retinopathy, and posterior capsular opacification.
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Affiliation(s)
| | - Christina A Mamalis
- Cullen Eye Institute, Department of Ophthalmology, Baylor College of Medicine, 1977 Butler Blvd, Houston, TX, 77030, USA
| | - Sumitra S Khandelwal
- Cullen Eye Institute, Department of Ophthalmology, Baylor College of Medicine, 1977 Butler Blvd, Houston, TX, 77030, USA.
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Hernandez-Bogantes E, Abdala-Figuerola A, Olivo-Payne A, Quiros F, Wu L. Cataract Following Pars Plana Vitrectomy: A Review. Semin Ophthalmol 2021; 36:824-831. [PMID: 34096468 DOI: 10.1080/08820538.2021.1924799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: The indications for pars plana vitrectomy (PPV) have increased over the years. The vitreous is no longer considered an inert ocular structure and it is well known that its removal has anatomical and physiological consequences. The vitreous is no longer considered an inert ocular structure. The vitreous plays a key role as an intraocular physiologic oxygen regulator. In order to maintain its transparency, the crystalline lens needs protection from an excessive oxygen exposure. PPV leads to progression of nuclear sclerosis in most eyes.Methods: A systematic review of the literature was conducted using Embase and Medline databases. Articles studying the physiology, pathogenesis and surgical treatment of cataract after PPV were included in this review.Results: The pathogenesis of cataract formation after PPV remains unclear. Predisposing factors include advanced patient age, preexisting nuclear sclerosis, light toxicity, intraoperative oxidation of lens proteins, use of silicone oil or intravitreal gas, mechanical trauma and the duration of exposure to an irrigating solution.Conclusion: Cataract surgery in vitrectomized eyes presents with more technical difficulties, is more challenging and often has a higher risk of intraoperative and postoperative complications than in non vitrectomized eyes. There is no standardized technique or management in these cases; therefore, it requires more precautions during surgery.
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Affiliation(s)
- Erick Hernandez-Bogantes
- Retina, Asociados De Macula Vitreo Y Retina De Costa Rica, San Jose, Costa Rica.,Centro Ocular, Heredia, Costa Rica
| | | | - Andrew Olivo-Payne
- Cuidad De Mexico, Insituto De Oftalmologia "Conde De Valenciana", Mexico City, Mexico
| | - Fabian Quiros
- Retina, Asociados De Macula Vitreo Y Retina De Costa Rica, San Jose, Costa Rica
| | - Lihteh Wu
- Retina, Asociados De Macula Vitreo Y Retina De Costa Rica, San Jose, Costa Rica.,Illinois Eye and Ear Infirmary, Dpt of Ophthalmology, University of Illinois School of Medicine, Chicago, Illinois, USA
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Bertens CJF, Gijs M, Dias AAJ, van den Biggelaar FJHM, Ghosh A, Sethu S, Nuijts RMMA. Pharmacokinetics and efficacy of a ketorolac-loaded ocular coil in New Zealand white rabbits. Drug Deliv 2021; 28:400-407. [PMID: 33594935 PMCID: PMC7894442 DOI: 10.1080/10717544.2021.1883157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Eye drops are considered standard practice for the delivery of ocular drugs. However, low patient compliance and low drug levels compromise its effectiveness. Our group developed a ketorolac-loaded ocular coil for sustained drug delivery up to 28 days. The aim of this study was to gain insight into the pharmacokinetics and efficacy of the ocular coil. The pharmacokinetics of the ketorolac-loaded ocular coil versus eye drops were tested in New Zealand White rabbits by repetitive sampling for 28 days. Efficacy of the ocular coil was also tested in New Zealand White rabbits. Ocular inflammation was induced where after the ocular coil was inserted, or eye drops, or no treatment was provided. The total protein concentration and cytokine levels were measured in tears, aqueous humor, and plasma at 4 h, 8 h, 24 h, 4 d, 7 d, 14 d, 21 d, and 28 d. Four h after inserting the ocular coil in the eye, ketorolac levels in aqueous humor and plasma were higher in the ocular coil group than in the eye drop group. Ketorolac released from the ocular coil could be detected up to 28 d in tears, up to 4 d in aqueous humor and up to 24 h in plasma. After inducing inflammation, both the ocular coil and eye drops were able to suppress prostaglandin E2, TNFα and IL-6 levels in aqueous humor and plasma as compared to the group that received no treatment. To conclude, the ocular coil facilitated a sustained release of the drug and showed similar therapeutic benefit in suppressing post-operative inflammation as eye drops.
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Affiliation(s)
- Christian J F Bertens
- Chemelot Institute for Science and Technology (InSciTe), Maastricht, The Netherlands.,University Eye Clinic Maastricht, Maastricht University Medical Center+ (MUMC+), Maastricht, The Netherlands
| | - Marlies Gijs
- Chemelot Institute for Science and Technology (InSciTe), Maastricht, The Netherlands.,University Eye Clinic Maastricht, Maastricht University Medical Center+ (MUMC+), Maastricht, The Netherlands
| | - Aylvin A J Dias
- Chemelot Institute for Science and Technology (InSciTe), Maastricht, The Netherlands.,Eyegle bv, Maastricht, The Netherlands
| | - Frank J H M van den Biggelaar
- Chemelot Institute for Science and Technology (InSciTe), Maastricht, The Netherlands.,University Eye Clinic Maastricht, Maastricht University Medical Center+ (MUMC+), Maastricht, The Netherlands
| | - Arkasubhra Ghosh
- GROW Research Laboratory, Narayana Nethralaya Foundation, Bangalore, India
| | - Swaminathan Sethu
- GROW Research Laboratory, Narayana Nethralaya Foundation, Bangalore, India
| | - Rudy M M A Nuijts
- Chemelot Institute for Science and Technology (InSciTe), Maastricht, The Netherlands.,University Eye Clinic Maastricht, Maastricht University Medical Center+ (MUMC+), Maastricht, The Netherlands
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