|Year : 2022 | Volume
| Issue : 3 | Page : 287-293
Short-term effects of prophylactic intravitreal injection of triamcinolone and moxifloxacin combination after cataract surgery
Emad A.A Saliem
Department of Ophthalmology, Al-Azhar Faculty of Medicine, Assiut, Egypt
|Date of Submission||02-Jan-2022|
|Date of Decision||07-Jun-2022|
|Date of Acceptance||20-Jun-2022|
|Date of Web Publication||11-Oct-2022|
MD Emad A.A Saliem
Tahta, Sohag 71524
Source of Support: None, Conflict of Interest: None
Background and Aim To evaluate the short-term effects and safety of prophylactic intravitreal injection of triamcinolone–moxifloxacin combination after cataract surgery.
Patients and methods This study included 100 eyes of 84 patients who underwent cataract surgery associated with intravitreal injection of triamcinolone–moxifloxacin combination after surgery. The patients were re-assessed at the first day, first week, and then monthly up to 3 months after surgery. The outcome measures included unplanned use of topical anti-inflammatory or anti-infective drugs during the postoperative period, best-corrected visual acuity (BCVA), and intraocular pressure (IOP). The mean age of patients was 55.99±5.20 years.
Results The mean BCVA showed a statistically significant difference between the preoperative and the postoperative values, where the mean BCVA improved from 1.21±0.27 logMAR before operation to 0. 83±0.25 logMAR at the first week, 0.46±0.21 logMAR at the first month, and 0.19±0.14 logMAR at the third month. The mean IOP revealed no statistically significant differences between preoperative and postoperative values at the end of the first month (P<0.084). The preoperative IOP ranged from 12 to 19 mmHg, with an average of 15.35±1.60 mmHg and became 14.52±1.11 mmHg at the end of the first month after surgery. There was no evidence of postoperative complications such as endophthalmitis or other complications such as retinal detachment and vitreous hemorrhage.
Conclusion Intravitreal injection of triamcinolone–moxifloxacin combination after cataract surgery can be used as an alternative to medications applied topically for prophylaxis against postoperative complications associated with cataract surgery such as infection and inflammation.
Keywords: cataract surgery, moxifloxacin hydrochloride, postoperative care, triamcinolone acetonide
|How to cite this article:|
Saliem EA. Short-term effects of prophylactic intravitreal injection of triamcinolone and moxifloxacin combination after cataract surgery. Al-Azhar Assiut Med J 2022;20:287-93
|How to cite this URL:|
Saliem EA. Short-term effects of prophylactic intravitreal injection of triamcinolone and moxifloxacin combination after cataract surgery. Al-Azhar Assiut Med J [serial online] 2022 [cited 2023 Jan 27];20:287-93. Available from: http://www.azmj.eg.net/text.asp?2022/20/3/287/358029
| Introduction|| |
Cataract accounts for ∼40% of global blindness cases. Although cataract is common, occurring in almost every aging population, the inequity of eye care means that 99% of these blinding cases are most commonly seen in developing countries . Over the past few years, modern techniques have been introduced to the field of cataract surgery, leading to marked improvement in visual outcomes after operation . Despite these advancements, all cataract surgeries may be subjected to the risk of postoperative complications, which may lead to loss of vision . Although it is rare, infectious endophthalmitis remains a serious complication that may threaten vision after cataract surgery. So, the current guidelines recommend the use of topical medications during the postoperative period to improve surgical results without overloading the patient and as a prophylactic measure to reduce the hazardous effects of postoperative complications such as endophthalmitis and inflammations . Despite topical eye drops being the current standard regimen during the postoperative period, they may be associated with patient noncompliance and may be expensive and sometimes include three or more medications to be applied several times/day, which may be extended up to several weeks . To overcome these difficulties with topical medications, alternatives have been suggested to be well tolerated and effective as prophylactic methods against postoperative inflammation and/or infection after cataract surgery by direct injection of steroid–antibiotic combination into the eye. An intracameral injection of antibiotics such as moxifloxacin has been shown to be well tolerated and effective at reducing the rate of postoperative endophthalmitis . Bowen et al.  found that when the moxifloxacin was used by intracameral injection, it can diminish the occurrence of endophthalmitis with minimal or no toxicity at the standard dose. Moxifloxacin hydrochloride is a sterile ophthalmic solution 0.5%. It is a fourth-generation fluoroquinolone antibacterial agent active against a broad spectrum of gram-positive and gram-negative ocular pathogens, atypical microorganisms, and anaerobes. It differs from other quinolones in that it has a methoxy function at the eight position and an S, S-configured diazabicyclononyl ring moiety at the seven position. It contains preservative-free active moxifloxacin 0.5% (5 mg/ml). Moreover, clinical studies have shown that an intracameral injection of steroids such as triamcinolone can safely prevent acute or persistent postoperative inflammation without significantly increased intraocular pressure (IOP) . Currently, intravitreal injection of moxifloxacin can be used successfully to treat the post-traumatic endophthalmitis as a result of metallic intraocular foreign body caused by multidrug-resistant gram-negative bacillus . In addition to that, Fisher and Potvin  had shown that intravitreal injection of steroid–antibiotic combination was safe and effective in reducing the risk of vision-threatening infections after cataract surgery.
Our study aimed to use intravitreal injection of triamcinolone–moxifloxacin combination at the end of cataract surgery as an alternative to the use of topical anti-inflammatory and/or anti-infective medications to evaluate and study their efficacy and safety as a prophylactic measure against vision-threatening complications after cataract surgery.
| Patients and methods|| |
A prospective, nonrandomized, noncomparative study was conducted that included 100 eyes of 84 patients (32 males and 52 females) who underwent cataract surgery with intravitreal injection of steroid–moxifloxacin combination at the end of surgery at Alforsan Eye Center, Assiut, between December 2020 and December 2021. Their ages ranged from 48 to 66 years, with a mean age of 55.99±5.20 years. Nine eyes of eight patients received topical anti-glaucoma medications in the form of dorzolamide+timolol before being included in this study. The study was conducted in accordance with Helsinki standards as revised in 2013. An informed written consent was taken from each patient included in this study. The study was approved by the Ethics Board of Al-Azhar University. Inclusion criteria included patients who underwent uncomplicated cataract surgery with a significant cataract, good control of diabetes mellitus and hypertension if present, and visual acuity not less than hand movement. Exclusion criteria included the use of systemic or topical steroids, topical ophthalmic antibiotics, or NSAIDs for 1 week before operation; undergoing an additional procedure at the same time with cataract surgery; those with uncontrolled glaucoma or with marked visual field defect; those with a significant macular edema owing to diabetes mellitus, hypertension, retinal vein occlusion, or any previous inflammatory condition; those with blepharitis or any other local disease interfering with surgical intervention or affecting the surgical outcome; and occurrence of intraoperative complications such as posterior capsular rupture or postoperative complications such as retained lens fragment.
All of the patients were subjected to complete preoperative ophthalmic assessment; detailed history including age and sex; assessment of the uncorrected and best-corrected visual acuity (BCVA); A-scan and occasionally B-scan ultrasonography in those with invisible fundus to dense cataract; assessment of IOP; anterior segment examination by slit-lamp before and after pupillary dilatation to assess the state of the cornea, iris, and degree of cataract; and fundus examination by indirect ophthalmoscope can be done if visible. Conjunctival swabs were performed preoperatively and revealed no pathogens. Other investigations were not done routinely before operation, however, they might be performed if possible and indicated as visual field (VF) & optical coherence tomography of optic disc especially in glaucoma patients to detect or exclude optic nerve affection as well as fluorescein angiography (FA) and OCT retina especially in diabetic patients. Once the diagnosis was confirmed, and after detailed explanation of risks and benefits of these medications and their purposes, all patients signed a written informed consent to participate in the study and for publication of data before enrollment in the study.
All of the patients underwent surgical removal of cataract by the same surgeon according to the standard protocols for modern phacoemulsification. Surgery was done under local anesthesia by peri-bulbar injection of local anesthetic. All operations were performed in operating room using an operating microscope (INFINITI Vision System, Alcon Laboratories Inc., California, USA) under complete aseptic condition using 10% povidone iodine solution applied to the skin of eye lid, eye lashes, side of the nose, eye brow, and the skin of forehead. Before the operation, sterile drape and eyelid speculum were used, and then 5% povidone iodine solution was applied to the bulbar conjunctiva and fornices for about 5 min, and then was irrigated by balanced salt solution (Alcon Laboratories, Forth Worth, Texas, USA). By the end of surgery, a combination of triamcinolone acetonide 4 mg and moxifloxacin 0.2 mg from 0.5 moxifloxacin hydrochloride preservative-free eye drop) were injected infero-temporally 3.5 mm posterior to the limbus via pars plana into the vitreous cavity by using 30G needle. [The commercial forms of the used drugs are called KENACORT − A (triamcinolone acetonide in the form of white crystals, along with an excipient) 40 mg/ml, SmithKline − Egypt L.L.C. and vigamox (moxifloxacin hydrochloride ophthalmic solution 0.5% preservative free (5 mg/ml) − Alcon Laboratories]. The needle was removed carefully using a sterile cotton applicator to prevent reflux. This was followed by gentle digital massage with assurance of watertight closure of the wounds by using a cellulose sponge.
All the patients were followed up on the first day, first week, first month, and on the third month after the operation.
At each visit, the following should be assessed: the postoperative refraction, BCVA, and anterior and posterior segment examinations for any sign of postoperative inflammation as cells and flare. IOP assessment and OCT images were also taken at the first and the third postoperative months to assess the central macular thickness in suspected cases of cystoid macular edema (CME) based upon symptoms or signs observed on fundus examination, which were confirmed by OCT of the macula through subjective interpretation via presence of cysts or an objective measurement of retinal thickness more than 250 μm.
The study end points included a condition of the eye after operation without the use of topical medications during the postoperative period, unplanned use of topical anti-inflammatory or anti-infective drugs during the postoperative period, postoperative BCVA, and postoperative IOP.
SPSS, version 22, was used for statistical analysis (IBM Corporation, Chicago, Illinois, USA). For statistical analysis, the BCVA data were transformed to LogMAR. We calculated the mean, SD, range, confidence interval, and Pearson correlation. The analysis of variance test was used, followed by the Tukey test, and P values of 0.05 were considered statistically significant. This was based on a calculated sample size of 90 participants to allow for the detection of a 0.9 change in BCVA (given an alpha of 0.05, beta of 0.9; some dropout was expected so the sample was raised to 100 participant). All participants signed an informed consent to participate in the study.
| Results|| |
An interventional clinical study was conducted that included 100 eyes of 84 patients who underwent cataract surgery with intravitreal injection of triamcinolone–moxifloxacin combination after cataract surgery. The demographic data of patients revealed that 32 patients were males and 52 patients were females, and the percentages of females and males were 62 and 38%, respectively. Their ages ranged from 48 to 66 years, with a mean age of 55.99±5.20 years. A total of 17 patients with bilateral cataract were included in this study. There were no statistically significant differences among the included groups regarding the age, sex, lens status, and laterality. The demographic data can be summarized in [Table 1].
The mean BCVA showed a statistically significant difference between the preoperative and postoperative values, where the preoperative BCVA ranged from 0.70 to 1.80 logMAR, with an average of 1.21±0.27 logMAR, and improved to 0.83±0.25 logMAR at the first postoperative week, to 0.46±0.21 logMAR at the first month and to 0.19±0.14 logMAR at the end of the third month after operation ([Table 2] and [Figure 1]). Regarding the postoperative visual acuity, 66% (66/100 cases) of included eyes revealed an improvement in monocular BCVA up to 0.2 or better (P<0.0001).
|Table 2 The mean best-corrected visual acuity at baseline, after first week, first month, and third month after operation|
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|Figure 1 The main best-corrected visual acuity (BCVA, log MAR) at baseline, after first week, first month, and third month after operation. BCVA, best-corrected visual acuity.|
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The mean IOP revealed no statistically significant differences between preoperative and postoperative values at the end of the first month (P<0.084). The preoperative IOP ranged from 12 to 19 mmHg, with an average of 15.35±1.60 mmHg, and became 17.50±1.47 mmHg at the first postoperative day, 15.50±1.29 mmHg at the first week, and 14.52±1.11 mmHg at the end of the first month after surgery ([Table 3] and [Figure 2]).
|Table 3 The mean intraocular pressure measurements at baseline, after first day, first week, and first month after operation|
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|Figure 2 The main intraocular pressure (IOP mmHg) at baseline, after first day, first week, and first month after operation. IOP, intraocular pressure.|
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The occurrence of an IOP rise was noticed clinically on the first postoperative days in seven eyes (7/100 eyes) not receiving any topical medications for glaucoma previously, and these cases were treated using topical medication for increased IOP not for more than 1 week, with complete improvement at the next visits. No cases required surgical intervention to control the IOP.
On anterior segment examination during the follow-up period, there was no evidence suggesting postoperative endophthalmitis or anterior chamber inflammation as cells and/or flare, photophobia, ciliary injection, or other manifestations that required supplemental anti-inflammatory medications. Persistent anterior chamber inflammation is an important anterior segment inflammation and can be defined as 2+ cell and/or flare at the first postoperative week.
Occurrence of a clinically significant corneal edema was noticed in few cases in the form of central Descemet folds or moderate endothelial edema on the first postoperative day, which were completely resolved within the a few days later by using topical steroid in the form of topical prednisolone acetate 1% eye drop four times/day (Optipred 5 ml; Jamjoom Pharmaceuticals Co., Jeddah, KSA), which was gradually tapered and discontinued within 2 weeks.
During the follow-up period, there were no symptoms or signs observed on fundus examination suggesting incidence of CME and also, OCT of the macula in suspected cases (as OCT imaging of the macula was not routinely performed in all patients) revealed no significant increase of retinal thickness more than 250 μm.
The incidence of subjective ‘floaters’ of variable degrees reported by the majority of patients was higher during the first visits, which were gradually subsided and disappeared during the next visits.
All included cases received a single dose of triamcinolone–moxifloxacin combination injected intravitreally after cataract surgery with no evidence of major intraoperative complications such as posterior capsule rupture or postoperative complications such as endophthalmitis or other major postoperative complications such as retinal tear and/or detachment, vitreous hemorrhage, persistent floaters, and persistent elevated IOP.
| Discussion|| |
Intraocular inflammation is one of the most serious vision-threatening complications that may occur after any intraocular surgical intervention such as cataract surgery .
Prophylactic pharmaceutical regimens are designed to decrease the likelihood and severity of infection, inflammation, and postoperative pain. Prophylactic medications are typically administered topically or through intraocular injection at the time of surgery, though postoperative prophylaxis is generally restricted to topical application. Noncompliance with ophthalmic topical drops has been reported to be as high as 40% . Modern prophylactic methods can be used to reduce the risk of postoperative endophthalmitis, inflammation, and CME, and their development is governed by the need to optimize surgical outcomes without unduly burdening the patient . One concern with intracameral delivery is the ability of a therapeutic agent to access the posterior segment. Studies in rabbit eyes have shown that agents administered by intravitreal injection achieve higher intraocular concentrations, persist longer (up to 3 months), and infiltrate most ocular tissues, including the retina and choroid, when compared with agents that are administered by intracameral injection .
An intravitreal injection of steroid–moxifloxacin combination after cataract surgery has been found to improve the surgical outcomes for the patient and the surgeon.
A randomized clinical study that was designed to compare a trans-zonular injection of a combined antibiotic-steroid versus topical medication concluded that patients preferred the former technique . Other study stated that patients receiving the combination drops in one eye and a single intraocular injection in the other eye had similar satisfaction and outcomes, though more patients preferred the injection to application of drops. One other study examined similar groups but included topical antibiotic application in the injection group, and the formulation was slightly different than the one used in the current study. In that study, the authors found that postsurgical inflammation (based on anterior chamber cell counts) was similar to or lower in the injection group when compared with the drops group . Another study was designed to compare the safety and efficacy of a pars plana injection of steroid–antibiotic combination with the use of a standard postoperative topical regimen in patients with primary open-angle glaucoma who underwent cataract surgery with triamcinolone–moxifloxacin–vancomycin placement. This study had determined that an intravenous injection of a combined steroid–antibiotic can be potentially given to patients with a history of increased IOP or those with mild to moderate primary open-angle glaucoma with no high risk of IOP elevation . These results were similar to our results which stated that after intravitreal injection after cataract surgery, no marked elevation of IOP could be detected in those receiving topical anti-glaucoma, and on the contrary, few cases of those not receiving anti-glaucoma medications previously reported a transient elevation of IOP, which was improved with topical hypotensive agents with no need for any surgical intervention.The current study is one of the recent studies that had been designed to study the short-term effects and safety of intravitreal injection of triamcinolone–moxifloxacin combination as prophylactic measures against postoperative complications associated with cataract surgery such as infection, inflammation, and CME. It included 100 eyes of 84 patients who underwent a cataract surgery associated with a single dose of intravitreal injection of a combination. Our results revealed that intravitreal injection of triamcinolone–moxifloxacin combination after cataract surgery reduced the need for additional postoperative medications, neither topical nor intravitreal injection, in most cases.
In the early postoperative period, floaters related to the injected triamcinolone that may affect the vision may be reported by many cases, so those were reassured that this complaint does not persist and will improve and disappear within a few days.
There was no evidence of major intraoperative or postoperative complications such as retinal detachment, vitreous hemorrhage, or macular edema related to cataract surgery along the follow-up period.
To the best of my knowledge, this is the first study to evaluate the short-term effects and safety of prophylactic intravitreal injection of triamcinolone–moxifloxacin combination after cataract surgery as a prophylactic measure to guard against major postoperative complications such as endophthalmitis without the need for topical ophthalmic medications during the postoperative period.
However, limitations of this study were the small sample size, a single location, short follow-up period which extended for 3 months only, and also selected patients with visual acuity not less than hand movements owing to cataract only were enrolled, with exclusion of other causes that may affect vision.
Future studies with a large sample size, multicenter trials involving many areas, and longer follow-up periods are required to determine the safety and efficacy of this new technique. Moreover, further studies may be needed to detect the optimal dose of combined triamcinolone–moxifloxacin needed for protection against endophthalmitis.
| Conclusion|| |
This study concluded that intravitreal injection of moxifloxacin and triamcinolone after uncomplicated cataract surgery is an alternative to topical medications for the prophylaxis against postoperative infection, inflammation, and CME associated with cataract surgery.
In addition, it seems to be cost-effective for patients, patients do not need to install postoperative topical medications frequently, and also it provides potential improvement in the surgical outcomes, which is not dependent on the frequent topical application of postoperative treatments for a long time.
The author thanks to dear colleagues for providing advice and suggestions during this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]