Best Innovations So Far in Science for 2016



Best Innovations So Far in Science for 2016



Even though we are still only in the early months of 2016. There are some big innovations that has to potential to revolutionize certain fields of medicine.


Within my own field of ophthalmology, Dropless Catarct Surgery has the potential to transform how we take care of patients needing cataract surgery. 


Thus my top 3 science innovations for January 2016 are:


1.  In cancer research: using cell-free DNA to find origin of a cancer. This has the potential to identify cancer even before standard cancer markers, such as PSA (Prostate Specific Antigen) become elevated. Though, it is still in its infancy, there is a hope that cell-free DNA can help patients be treated for significant cancer faster and improve survival rates even more. It was only a few years ago that Dr. Judah Folkman, one of my advisers at Harvard pushed the revolutionary idea of treating the Cancer Marker before even really seeing any disease: thus he would encourage patients to go onto the next step of treatment if the PSA went up even if they did not see prostate cancer lighting up on scans. Many thought this was a ridiculous idea, but he saved many lives doing this, in general. Time will tell if cell-free DNA will have the same potential to save lives. 


2. Using your smartphone with an adapter to test your blood. See below:

Magnetic Device Lets Smartphones Test Your Blood

We are hopefully getting closer to the Star Trek time where we can magically move our iphone across a patient’s body and determine 


3. Dropless Cataract Surgery: started in 2015 but will likely take off in 2016.
The FDA approved drops which we have used for years after cataract surgery have been combined to into an injectable solution called Trimoxi (intravitreal triamcinolone/moxifloxacin, Imprimis Pharmaceuticals). Though Trimoxi has not been FDA approved yet, it does contain FDA approved drugs. Trimoxi has the potential to prevent postoperative inflammation, cystoid macular edema (CME), and endophthalmitis. Even more so, studies from Europe, where they have been injecting antibiotics into the eye after cataract surgery for years, have shown that injecting antibiotics into the eye is more effective than antibiotic eye drops in preventing endophthalmitis which is a devastating eye infection, I pray none of my patients will ever have.


This recent publication below published in the prestigious Ophthalmology Journal notes that patients receiving intracameral (injected into the eye) antibiotics was 100% effective against endophthalmitis.


 2015 Dec 15. pii: S0161-6420(15)00844-1. doi: 10.1016/j.ophtha.2015.08.023. [Epub ahead of print]

Endophthalmitis Occurring after Cataract Surgery: Outcomes of More Than 480 000 Cataract Surgeries, Epidemiologic Features, and Risk Factors.

Jabbarvand M1, Hashemian H2, Khodaparast M1, Jouhari M1, Tabatabaei A1, Rezaei S3.

Author information

  • 1Department of Ophthalmology, Ophthalmology Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran.
  • 2Department of Ophthalmology, Ophthalmology Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran. Electronic address: shhlucky@yahoo.com.
  • 3Department of Ophthalmology, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran.

Abstract

PURPOSE:

To report the incidence of endophthalmitis after senile cataract surgery and to describe the epidemiology and main risk factors.

DESIGN:

Retrospective, single-center, cross-sectional descriptive study.

PARTICIPANTS:

Patients who underwent cataract surgery in Farabi Eye Hospital from 2006 through 2014.

METHODS:

All patients were evaluated retrospectively to compare risk factors, epidemiologic factors, and prophylaxis methods related to endophthalmitis. Patient records were used to gather the data.

MAIN OUTCOME MEASURES:

Epidemiologic factors, systemic diseases, other ocular pathologic characteristics, complications during the surgery, technique of cataract surgery, intraocular lens type, method of antibiotic prophylaxis, surgeon experience, vitreous culture, and vision outcome were evaluated in these patients.

RESULTS:

One hundred twelve endophthalmitis cases among 480 104 operations reported, equaling an incidence of 0.023%. Patients with diabetes mellitus (14.3%) and of older age (mean age, 81 years), perioperative communication with the vitreous (17.9%), extracapsular cataract surgery procedure (11%), and surgery on the left eye (58.9% vs. 41.1% for right eye; P = 0.03) showed a statistically significant association with endophthalmitis. Short-term treatment with topical or systemic preoperative antibiotics or postoperative subconjunctival injection was associated with a 40% to 50% reduced odds of endophthalmitis compared with no prophylaxis (P = 0.2). No cases of endophthalmitis were observed among the 25 920 patients who received intracameral cefuroxime, suggesting that this approach to antibiotic prophylaxis may be far more effective than traditional topical or subconjunctival approaches.

CONCLUSIONS:

The incidence of endophthalmitis after cataract surgery in our center was 0.023%, comparable with that of other previously published international studies. Older rural patients with immune suppressive diseases, such as diabetes mellitus, are particularly more prone to endophthalmitis. Vitreous loss at the time of surgery was associated with a significantly increased risk. Whereas antibiotic prophylaxis overall showed a 40% to 50% reduction in risk, intracameral cefuroxime was 100% effective in preventing endophthalmitis in this series.

References:
I.
From NYT:


Searching for Cancer Maps in Free-Floating DNA

Carl Zimmer
MATTER JAN. 14, 2016


Jay Shendure, a geneticist at the University of Washington. Dr. Shendure and his colleagues have taken important steps toward identifying the origins of cell-free DNA, which could have ramifications in finding clues about diseases.


Cell-free DNA is like a message in a bottle, delivering secrets about what’s happening inside our bodies. Pregnant women, for example, carry cell-free DNA from their fetuses. A test that analyzes fetal DNA has proved to be more accurate in screening for Down syndrome than standard blood tests.Loose pieces of DNA course through our veins. As cells in our body die, they cast off fragments of genes, some of which end up in the bloodstream, saliva and urine.
In 2012, Jay Shendure, a geneticist at the University of Washington, and his colleagues were able to reconstruct the entire genome of a fetus from cell-free DNA in a pregnant woman’s saliva. A team of Stanford University researchers collected DNA fragments from the blood of patients who had received heart transplants and managed to find DNA from their donated hearts. (Tellingly, levels were highest in patients who were rejecting their hearts.)

These days, scientists are especially excited by the prospect of using cell-free DNA to test for cancer. Instead of relying on invasive biopsies, they hope to find blood-borne fragments that carry distinctive cancer mutations.
Unfortunately, the genetic sequence of a piece of cell-free DNA doesn’t tell researchers where in the body it originated — a valuable clue for doctors looking for diseases. “Knowing the origin of circulating DNA is of great importance,” said Alain R. Thierry, director of research at France’sNational Institute of Health and Medical Research.
All the cells in our body typically descend from a single fertilized egg, and they inherit all the same genes. The reason we aren’t uniform sacs of protoplasm is that our cells turn those same genes on and off in distinctive patterns, thereby developing into different tissues. They’re like musicians at a piano recital: They sit at the same keyboard, but they play different songs.

But in a study published on Thursday in the journal Cell, Dr. Shendure and his colleagues took some important steps toward identifying the origins of free-floating DNA. To do so, they took advantage of a way that cells control their genes.
DNA is wound around millions of protein clusters, resembling beads on a string. Some genes sit on stretches of DNA unencumbered by these clusters, called nucleosomes, but other genes are tucked deep inside them. By hiding genes, nucleosomes can silence them.
As it turns out, different types of cells squirrel away different stretches of DNA in nucleosomes. One of Dr. Shendure’s graduate students, Matthew W. Snyder, wondered what happened to those nucleosomes in dying cells.
A cell ending its useful life is shredded by enzymes. But nucleosomes, Mr. Snyder suggested, might shield the DNA they’ve hidden.
If so, then much of the cell-free DNA that scientists collect from blood samples should have come from nucleosomes. They could reveal the pattern of nucleosomes in the cells they came from — and thus tell researchers which kind of cell produced it.
Mr. Snyder and his colleagues put the idea to the test. They searched the blood of healthy individuals for cell-free DNA, and then searched a map of the human genome to figure out where each fragment came from. Much of the cell-free DNA came from regions in or around nucleosomes, just as Mr. Snyder had suggested.
But when they looked at cell-free DNA from people with advanced cancer, the picture was different.The scientists then looked at the patterns of nucleosomes in different types of cells. They found that all the healthy subjects produced cell-free DNA that mainly came from nucleosomes found in blood cells.
In a patient with lung cancer, for example, the team found that the cell-free DNA fit a different pattern — one belonging to a type of lung cancer cell. The researchers went on to match cell-free DNA in other cancer patients to the types of cancer they had.
Dr. Thierry, who was not involved in the research, said the findings might eventually make it possible to use cell-free DNA to find important clues about diseases. Doctors might be able to use it to figure out the location of hard-to-find cancers, for example.
It could provide clues to diseases other than cancers as well. Free-floating genes shed by the heart, for example, might reveal damage from a heart attack. Cell-free DNA from neurons might signal a stroke.
William J. Greenleaf, a geneticist at Stanford, cautioned that the success of the new study owed much to the people Dr. Shendure and his colleagues had studied. It has long been known that people with advanced cancer shed a lot of cell-free DNA from their tumors. It may prove harder to trace the origin of cell-free DNA in people with other conditions.
Dr. Shendure agreed, calling his study a proof of concept — far from a test ready for the clinic.
“Obviously, there’s a lot of work from here to there,” he said.



II. References for DROPLESS CATARACT SURGERY:


Dropless cataract surgery offers ‘significant benefit’


Using an intravitreal transzonular injection improves patient compliance while maintaining good outcomes

January 01, 2015
By Michelle Dalton
TAKE HOME
Examining how utilizing an intravitreal transzonular injection can help patient compliance.
By Michelle Dalton, ELS; Reviewed by M. Stewart Galloway, MD
Crossville, TN—Intravitreal transzonular antiobiotic/steroid combination concurrent with cataract surgery can provide a “significant benefit with minimum risk,” said M. Stewart Galloway, MD, Cumberland Eye Care, Crossville, TN.
Trimoxi (intravitreal triamcinolone/moxifloxacin, Imprimis Pharmaceuticals) following phacoemulsification with IOL implantation “is able to prevent postoperative inflammation, cystoid macular edema (CME), and endophthalmitis,” said Dr. Galloway, Cumberland Eye Care (Tenn.).
More in this issue: In search of the sutureless closure
It is common practice to deliver antibiotics topically, but with Trimoxi, the delivery is transzonular. Trimoxi is compounded, preservative-free triamcinolone acetonide and moxifloxacin delivered 15 mg/1mg/ml, with 0.2 ml injected transzonularly into the anterior vitreous, Dr. Galloway said, resulting in a total drug delivery of 3 mg triamcinolone and 0.2 mg of moxifloxacin.
“After the lens implant is in place, and prior to removing viscoelastic, you pass a cannula through the incision, over the anterior capsule, underneath the iris, and then penetrate the zonules into the anterior vitreous so the drug is delivered into the vitreous itself,” Dr. Galloway said.
Unlike intracameral injections, which go into the anterior chamber, Trimoxi is designed to be delivered to the posterior chamber, directly into the vitreous, he said.
In his retrospective chart review of 2,300 consecutive eyes that underwent phaco/IOL implantation with the use of Trimoxi instead of topical antibiotic/steroids postoperatively, not one eye has developed endophthalmitis.
“There have been more than 14,000 eyes injected with Trimoxi—not all at our center, of course—and while we can’t say we have a zero rate of endophthalmitis, we can say it’s zero thus far,” he said.
Dr. Galloway said he believes the reason Trimoxi has yet to result in a single case of endophthalmitis is because when bacteria do enter the eye, it colonized in the vitreous.
“It’s a nutrient-rich place, and that’s where the bacteria grow and cause the problems,” he said. “We put the antibiotic where the bacteria want to grow. We’re not putting drops on the cornea and hoping they diffuse into the eye, we’re not delivering them intracamerally and hoping some of it gets through to the vitreous.”
He noted that a problem with intracameral injections is that “the drug is washed out of the eye in a fairly short time frame,” he said. In rabbit eyes, conversely, “the moxifloxacin stays at therapeutic concentrations for at least eight hours. The anti-inflammatory portion is detectable there for months afterwards.”
Study details
In Dr. Galloway’s study, all patients were seen day of surgery (4-7 hours postoperatively). All patients were then seen between 3 and 4 weeks postoperatively, and then again at 6 months.
Of the original 2,300 patients, only 10 were lost to follow-up. The average age was 73 years (ranging from 34 to 95 years old). Almost one-fifth of the eyes/patients had diabetes, and 5% presented with epiretinal membrane (ERM).
Dr. Galloway said 19% of the patients received supplemental topical nonsteroidal anti-inflammatory drugs (NSAIDs) because of diabetes, ERM, or premium IOL implantation.
The rate of breakthrough inflammation requiring the addition of topical steroids during the postop period was 2% but was “slightly higher at 3.5% in those with ERM, and 6.3% in those who developed CME,” Dr. Galloway said. Mean intraocular pressure fell from 21.1 mm Hg on day of surgery to 14.1 mm Hg at weeks 3-4 postop, he added.
The overall CME rate in the study was 1.4% (see Figure 1).  The rate of CME in the diabetic subgroup was slightly higher at 1.9% and not significantly altered with the addition of topical NSAIDs.  In the ERM subgroup however, the CME rate was very significantly affected by the topical NSAID, decreasing from 8.5% without to 2.2 % with topical NSAIDs.  Dr. Galloway added he now routinely uses NSAIDs only on patients with ERMs and no longer uses them on diabetic patients without pre-existing maculopathy.
With the diabetic patient population, “if there’s no maculopathy, then there’s no reason to treat them differently than someone without diabetes,” he said.
There are some disadvantages to the procedure, he said—primarily that patients experience decreased immediate postop vision and floaters, due to the opaque nature of the drug. There also may be an increased incidence of patients who experience foreign body sensation, “presumably due to a lack of topical anti-inflammatory drugs at the wound itself,” he said.
Patient compliance
By not relying on postoperative drops to control potential inflammation, Dr. Galloway said there’s also no issue with patient compliance.
Calling the use of Trimoxi “truly a dropless surgery, there’s decreased patient cost as well, and a decrease in postop care,” he said, explaining the lack of postop drops eliminates numerous call backs related to pharmacy and drop regimen.
“There’s enormous potential for this in Third World countries, where follow-up care is less than ideal,” he said.

M. Stewart Galloway, MD


III.


Follow up Protocol: For all Dropless Patients:
1. See patient day of surgery about 4 hrs after surgery
2. See all patients 3wks-4wks post op for refraction & dilation
3. See patients at 6 months.

Dropless Protocol Suggestions:
1. All patients sign a consent form including Dropless option.
2. All patients reminded that they will see floaters and a cloud over their vision for the first 2-3 days but should not have worsening pain. IF they have pain other than a foreign body sensation, they should come in ASAP.
3. All patients with diabetes, ERM, previous uveitis or HSV uveitis, or premium IOL implantation: will need Prolensa or Ilevro qday for 1 month; or Generic NSAID like ketorolac tid 2-3 weeks.
2. All patients should have a prescription or sample for below as needed (PRN) for pain or discomfort: Prolensa or Ilevro qday for 1 month; or Generic NSAID like ketorolac tid 2-3 weeks.


References:
1.

Dropless cataract surgery offers ‘significant benefit’

Using an intravitreal transzonular injection improves patient compliance while maintaining good outcomes

January 01, 2015
TAKE HOME
Examining how utilizing an intravitreal transzonular injection can help patient compliance.
By Michelle Dalton, ELS; Reviewed by M. Stewart Galloway, MD
Crossville, TN—Intravitreal transzonular antiobiotic/steroid combination concurrent with cataract surgery can provide a “significant benefit with minimum risk,” said M. Stewart Galloway, MD, Cumberland Eye Care, Crossville, TN.
Trimoxi (intravitreal triamcinolone/moxifloxacin, Imprimis Pharmaceuticals) following phacoemulsification with IOL implantation “is able to prevent postoperative inflammation, cystoid macular edema (CME), and endophthalmitis,” said Dr. Galloway, Cumberland Eye Care (Tenn.).
It is common practice to deliver antibiotics topically, but with Trimoxi, the delivery is transzonular. Trimoxi is compounded, preservative-free triamcinolone acetonide and moxifloxacin delivered 15 mg/1mg/ml, with 0.2 ml injected transzonularly into the anterior vitreous, Dr. Galloway said, resulting in a total drug delivery of 3 mg triamcinolone and 0.2 mg of moxifloxacin.
“After the lens implant is in place, and prior to removing viscoelastic, you pass a cannula through the incision, over the anterior capsule, underneath the iris, and then penetrate the zonules into the anterior vitreous so the drug is delivered into the vitreous itself,” Dr. Galloway said.
Unlike intracameral injections, which go into the anterior chamber, Trimoxi is designed to be delivered to the posterior chamber, directly into the vitreous, he said.
In his retrospective chart review of 2,300 consecutive eyes that underwent phaco/IOL implantation with the use of Trimoxi instead of topical antibiotic/steroids postoperatively, not one eye has developed endophthalmitis.
“There have been more than 14,000 eyes injected with Trimoxi—not all at our center, of course—and while we can’t say we have a zero rate of endophthalmitis, we can say it’s zero thus far,” he said.
Dr. Galloway said he believes the reason Trimoxi has yet to result in a single case of endophthalmitis is because when bacteria do enter the eye, it colonized in the vitreous.
“It’s a nutrient-rich place, and that’s where the bacteria grow and cause the problems,” he said. “We put the antibiotic where the bacteria want to grow. We’re not putting drops on the cornea and hoping they diffuse into the eye, we’re not delivering them intracamerally and hoping some of it gets through to the vitreous.”
He noted that a problem with intracameral injections is that “the drug is washed out of the eye in a fairly short time frame,” he said. In rabbit eyes, conversely, “the moxifloxacin stays at therapeutic concentrations for at least eight hours. The anti-inflammatory portion is detectable there for months afterwards.”
Study details
In Dr. Galloway’s study, all patients were seen day of surgery (4-7 hours postoperatively). All patients were then seen between 3 and 4 weeks postoperatively, and then again at 6 months.
Of the original 2,300 patients, only 10 were lost to follow-up. The average age was 73 years (ranging from 34 to 95 years old). Almost one-fifth of the eyes/patients had diabetes, and 5% presented with epiretinal membrane (ERM).
Dr. Galloway said 19% of the patients received supplemental topical nonsteroidal anti-inflammatory drugs (NSAIDs) because of diabetes, ERM, or premium IOL implantation.
The rate of breakthrough inflammation requiring the addition of topical steroids during the postop period was 2% but was “slightly higher at 3.5% in those with ERM, and 6.3% in those who developed CME,” Dr. Galloway said. Mean intraocular pressure fell from 21.1 mm Hg on day of surgery to 14.1 mm Hg at weeks 3-4 postop, he added.
The overall CME rate in the study was 1.4% (see Figure 1).  The rate of CME in the diabetic subgroup was slightly higher at 1.9% and not significantly altered with the addition of topical NSAIDs.  In the ERM subgroup however, the CME rate was very significantly affected by the topical NSAID, decreasing from 8.5% without to 2.2 % with topical NSAIDs.  Dr. Galloway added he now routinely uses NSAIDs only on patients with ERMs and no longer uses them on diabetic patients without pre-existing maculopathy.
With the diabetic patient population, “if there’s no maculopathy, then there’s no reason to treat them differently than someone without diabetes,” he said.
There are some disadvantages to the procedure, he said—primarily that patients experience decreased immediate postop vision and floaters, due to the opaque nature of the drug. There also may be an increased incidence of patients who experience foreign body sensation, “presumably due to a lack of topical anti-inflammatory drugs at the wound itself,” he said.
Patient compliance
By not relying on postoperative drops to control potential inflammation, Dr. Galloway said there’s also no issue with patient compliance.
Calling the use of Trimoxi “truly a dropless surgery, there’s decreased patient cost as well, and a decrease in postop care,” he said, explaining the lack of postop drops eliminates numerous call backs related to pharmacy and drop regimen.
“There’s enormous potential for this in Third World countries, where follow-up care is less than ideal,” he said.
M. Stewart Galloway, MD

November 2014

CATARACT
‘Dropless’ approach to cataract surgery expands
by Vanessa Caceres EyeWorld Contributing Writer
Use of the injectable formulation has helped improve staff workflow. “Staff time at the office and ASC has been greatly reduced with shorter instructions and calls and fewer call backs to pharmacies.” – Ahad Mahootchi, MD

Injection of TriMoxi
TriMoxi reflex Source (all): M. Stewart Galloway, MD
Injectable formulation aims to boost medication compliance, decrease patient cost
Getting patients to comply with their post-cataract surgery drop regimen can be challenging, to say the least—and then patients balk at the out-of-pocket expenses associated with those drops.
One pharmaceutical company hopes to make the drop regimen a little simpler for both surgeons and patients.
Imprimis Pharmaceuticals (San Diego) has developed sterile and injectable proprietary compound formulations for ophthalmology that became available after the company launched its Go Dropless campaign in April 2014. One formulation, called TriMoxiVanc, combines triamcinolone, moxifloxacin, and vancomycin. A second formulation, called TriMoxi, contains only triamcinolone and moxifloxacin. In addition to cataract surgery, the formulations can be used with other intraocular procedures.
A study presenting some of the first data on the preservative-free injections reported that TriMoxi helped to prevent inflammation, cystoid macular edema (CME), and endophthalmitis after phacoemulsification. At the 2014 ASCRS•ASOA Symposium & Congress in Boston, M. Stewart Galloway, MD, Crossville, Tenn., presented his retrospective chart review of 1,575 eyes that had received TriMoxi instead of topical antibiotics and steroids. Dr. Galloway injected 0.3 mg of triamcinolone and 0.2 mg of moxifloxacin transzonularly into the anterior vitreous of patients undergoing cataract surgery. The injections occurred with the use of a 27-gauge cannula before removing viscoelastic material.
Follow-up evaluations took place at 4 to 7 hours, 3 to 4 weeks, and at 6 months.
The mean IOP was 21.8 mm Hg on the day of surgery and 14.5 mm Hg at 3 weeks. “No patients required ocular hypotensives due to a steroid response,” Dr. Galloway said.
There were no cases of endophthalmitis. Dr. Galloway defined CME as any patient with reduced postop visual acuity and any increase in cystoid macular thickness more than 220 μm regardless of the presence or absence of cystic change on OCT. The overall CME rate was 2% in the study overall, but only 1.5% in those without the risk factors of diabetes or epiretinal membranes.
The overall inflammation rate was 2.5% postoperatively, and those patients required the short-term addition of topical steroids. The inflammation rate was higher in patients with an epiretinal membrane and those who later developed CME. The injectable approach improved patient medication compliance and decreased postop care requirements. The injection did, however, require slightly more preoperative counseling and led to an increasing number of patients who had a foreign body sensation, which Dr. Galloway attributed to the lack of topical anti-inflammatory use at the wound. The additional counseling came from explaining to patients that they would experience a brief reduction in visual acuity after surgery and to let them know that they would “see” the medication appear as floaters for several days after surgery. Further presentations on the “dropless” approach will be presented at upcoming ophthalmology meetings.
The formulations from Imprimis are currently patent pending. Imprimis acquired the intellectual rights to the formulations in August of last year.
As of June 2014, the formulations were available in 29 states with a physician’s prescription. The company has compounding pharmacy license applications pending in 10 additional states.

Practice implications

“Far more often than we may think, patients do not take their medications in the way we prescribe them,” said Kevin T. Scripture, MD, Richmond, Ind.
That is where Dr. Scripture thinks that going dropless will be quite useful. Dr. Scripture, who has used compounded drug formulations since May 2005 in more than 20,000 patients, said the only anomaly he must stress to patients is that they will see floaters or shadows of the medication for several days after surgery. “It’s in a spot in the eye that will cast shadows on the retina,” he said. In very rare cases—maybe one in every 2,000—bleeding will occur from the injection hitting the ciliary body, Dr. Scripture said. However, that has never caused long-term problems.
Although some surgeons may be concerned about an IOP increase, Dr. Scripture said this happens about as often as it would with the use of topical drops.
The only time Dr. Scripture will avoid the injection is if a patient has related medication allergies.

Pearls, praises, and concerns

Ahad Mahootchi, MD, Zephyrhills, Fla., said that using the injectable formulation in more than 500 patients since last year has been a process. “I did get rid of the postop antibiotic drops from the start. Reducing or eliminating the steroid or nonsteroidal drops has been a slower process,” he said. After several months of trial and error, he is down to one drop of NSAID a day.
“In my early days with it, I tried leaving a little in the anterior chamber under the inferior iris—not necessary or desirable. I tried using the leftover drug subconjunctivally, which wasn’t necessary. Now I just use the leftover drug on the cornea at the end of the case,” he said.
He previously saw quiet eyes in most eyes on postop day 1 and at all visits after that point; now, half of the eyes are 20/25 or better on day 1. He has not seen inflammatory issues in the first 2 weeks; his patients have experienced floaters only in the first 24 hours.
Dr. Mahootchi has found it helpful to individualize what drops, if any, patients use, and he still recommends lubricant drops for the first few days after surgery. Use of the injectable formulation has helped improve staff workflow. “Staff time at the office and ASC has been greatly reduced with shorter instructions and calls and fewer call backs to pharmacies,” he said.
A pearl to consider is how one performs the injection, Dr. Mahootchi said. “I use the same 30-gauge cannula for TriMoxiVanc that I use for intracameral anesthesia. I slide the cannula through the inferonasal zonules. I have checked with an endoscopic cyclophotocoagulation probe, and the zonules don’t get damaged. Much of the drug sits 360 degrees around the ciliary processes,” he said.
Steven G. Safran, MD, Lawrenceville, N.J., is intrigued by the formulation, although he has not yet tried it. “I’m interested in seeing how it plays out,” he said. He has not had any endophthalmitis cases with his current approach, so he is not motivated to change his regimen. Still, he likes the idea of avoiding compliance headaches. One of his concerns would be contamination sometimes associated with compounded injectables, he added. Another would be any issue with the use of the Crystalens (Bausch + Lomb, Bridgewater, N.J.), where injecting the formulation into the vitreous at the end of the case could possibly cause an anterior vault.
Dr. Mahootchi sees a difference in patient results, based on the amount of steroid that reaches the vitreous. That seems to affect iritis flare-ups at 3 weeks out. “I think you have to get at least 0.2 cc of the drug into the vitreous. There is more rebound iritis 3 weeks postop with 0.15 cc, so getting the volume up is important.” An endoscopic study done informally by Dr. Mahootchi with the Crystalens has shown that the approach is not damaging zonules.
In the rare occasions that Dr. Mahootchi sees a capsular block at day 1, it will resolve spontaneously, or he will push the lens back off the anterior capsule in the office. “The inflated vitreous probably pushed the lens forward, and a seal forms to the anterior capsule,” he said.
“The final refractive result is unaffected. I haven’t seen a vault since injecting more slowly and spending a few seconds at the end of the case to tap vaulting thin lenses back toward the posterior capsule.”

Editors’ note: Drs. Galloway and Mahootchi have financial interests with Imprimis. Drs. Safran and Scripture have no financial interests related to their comments.

——

Advantages plentiful with dropless cataract surgery

The technique is effective, saves time and money, and has good results.
Ocular Surgery News U.S. Edition, May 25, 2014
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, 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
—–

Article Date: 5/1/2014


 Print Friendly Page

A case for dropless cataract surgery

A single prophylactic injection is gaining growing support.

BY JERRY HELZNER, SENIOR EDITOR

Cataract surgeon Jeffrey T. Liegner, MD, is once again on a mission. The former Air Force flight surgeon, whose practice is Eye Care Northwest in Sparta, N.J., aims to convince his colleagues that a single intravitreal injection of a steroid-antibiotic combination, delivered intraoperatively, can replace the traditional patient-administered prophylaxis of antibiotic eyedrops.
Dr. Liegner estimates he has safely performed 4,000 cataract operations with the single-injection approach. The advantages of this method, he says, comes down to “The Three Cs” — cost, compliance and convenience.

THE THREE CS

Cost
“The cost to the patient of eyedrops has become an increasingly critical issue, running to hundreds of dollars in out-of-pocket expense,” says Dr. Liegner, noting that in recent years higher co-pays, more limited formularies and restricted availability of samples have all contributed to the costs the patient bears.
“We were running into distracting pre-authorizations and unannounced substitutions of drugs, which creates more work for the doctors and less protection for the patient,” he says. “In 2010, I recognized that an alternative to topical antibiotics and steroids was becoming more and more important to the practicing eye surgeon. I began to query ASCRS members to see if any of them thought the same way and I found Dr. Kevin Scripture in Indiana who had been using an antibiotic-steroid combination he had been getting from a compounding pharmacy. That’s when I started my own search for a cost-effective stable and consistent combination of this type.”
Compliance
The single injection eliminates compliance issues, says Dr. Liegner. “It is a no-brainer,” he says. “The injection effectively inoculates the patient against infection. I don’t have to worry about it even if the patient is a charity case or one I see during an overseas mission and never see again.”
In his regular practice, he has encountered patients with so-called “eyedrop phobia” who cannot — or will not— self-administer eyedrops. He also notes difficulties that many patients have in instilling eyedrops effectively. Other patients may forget to adhere to the demanding postoperative regimen for using the drops.
“We don’t have to worry about any of those issues,” says Dr. Liegner. “I cannot remember a patient who requested drops after I explained the single injection to them.”
Convenience
“The single injection is more convenient for everyone involved in the procedure, including the surgeon, the patient, the office staff and the ASC staff,” says Dr. Liegner. “Just the time spent giving the patient the instructions for using the drops is well worth saving. The ASC is a high-cost environment, and I found we can save four minutes a case by bypassing the drops. With 20 cases a day, we are saving real money.”
Dr. Liegner says some surgeons may be wary that injecting a steroid (triamcinolone) could cause elevated IOP but he has not found that to be the case.
“The combination I use today is triamcinolone acetonide combined with moxifloxacin hydrochloride and vancomycin,” says Dr. Liegner. “With the 2.5 to 3 mg of triamcinolone I use, the incidence of elevated IOP is near zero.”
Growing interest in single injection
Though Dr. Liegner estimates that only about 50 cataract surgeons are currently routinely using single-injection prophylaxis, he confidently predicts that the number will rise sharply in the near future.
Video of combined steroid-antibiotic IVI procedure
The video “Transzonular intravitreal injection of triamcinolone and moxifloxacin after IOL Insertion in lieu of preop/postop eyedrops” from ASCRS 2012 is available at http://ascrs2012.conferencefilms.com/atables.wcs?entryid=100047. The link can be accessed atwww.ophthalmologymanagement.com.
“I am getting calls every day from the United States and overseas asking for information and advice on adopting the single injection,” he says. “Another cataract surgeon, Dr. James Lewis of Elkins Park, Pa., has also been giving presentations at meetings and noting all the advantages he has found with the single injection.”
In February, Dr. Lewis reviewed his successful use of single-injection prophylaxis and his transzonular administration technique in more than 400 cases at the American-European Congress of Ophthalmic Surgery meeting in Aspen, Colo.
“Experience with this compound now exceeds 14,000 procedures,” says Dr. Lewis. “Fewer than 10% of patients require steroid rescue at some point in their postoperative management.”
Because the FDA does not require formal studies of these types of combination drugs, the experiences and insights individual surgeons such as Drs. Lewis and Liegner provide can be valuable in driving wider adoption.
The Imprimis factor
What Dr. Liegner believes will most spur adoption of the single injection is the recent entrance of the drug development company Imprimis Pharmaceuticals (San Diego) into the arena.
Imprimis sees itself as a pharmaceutical hybrid, marrying the high-quality manufacturing standards of a traditional drug company with the ability of a compounding pharmacy to innovate and handle individual orders such as the steroid-antibiotic combinations.
“What Imprimis brings to the equation is the manufacturing, distribution and marketing skills that will bring the single injection into widespread acceptance,” says Dr. Liegner, who has signed on as a consultant to Imprimis.
Commercializing the combination
When Dr. Liegner began his own search for a compounding pharmacy that could produce a safe and effective steroid-antibiotic combination for use in cataract surgery, he first went to Pharmacy Creations (Randolph, N.J), which is accredited by the Pharmacy Compounding Accreditation Board and already had a relationship with his practice.
“We had obtained other products from Pharmacy Creations and I knew they were very much involved with national policy on accreditation and good manufacturing procedures,” says Dr. Liegner. “I visited them to film their process for my own review and due diligence.”
The first product Dr. Liegner obtained from Pharmacy Creations was a combination of triamcinolone and moxifloxacin (TriMoxi) that he used on every cataract surgery case and that Dr. Scripture also adopted. It took the compounder another year to get stable vancomycin into the mix.
“Once that occurred in 2011, I have used [TriMoxi+Vancomycin] on every cataract and intraocular procedure since,” says Dr. Liegner.
Seeking wide adoption
Imprimis made its initial move to commercialize the TriMoxi+Vancomycin combination by acquiring Pharmacy Creations in February.
“Our goal is to eventually have three to five high-quality manufacturing sites around the country to produce and distribute drugs that are brought to us by doctors and other innovators,” says Mark Baum, CEO of Imprimis. “We are putting an initial focus on ophthalmology but we are also looking at drugs for other specialties.”
Reaching critical mass
Dr. Liegner is certain that single-injection prophylaxis is an idea whose time has come. He sees all the elements now coming together to convert thousands of cataract surgeons to the concept.
“For awhile, we were just a few isolated cataract surgeons raising our hands, jumping up and down to be recognized,” he says. “Now, we are reaching the critical mass that will get the attention of cataract surgeons everywhere.”

My pearls for using TriMoxi+Vancomycin

A bit of practice makes for perfect technique.

BY JEFFREY T. LIEGNER, MD

I have assembled a number of pearls that will help the surgeon gain assurance with using single-injection prophylaxis.

Basic advantages of TriMoxi+Vancomycin

TriMoxi+Vancomycin, or, as I call it, TriMoxiVanc, comes in a 1-ml single-dose vial of preservative-free triamcinolone 15 mg/ml with moxifloxacin 1 mg/ml and vancomycin 10 mg/ml properly assembled, buffered and stabilized for intraocular injection. The product will be distributed nationally through Imprimis Pharmaceuticals (San Diego) under the stringent industry standards for pharmaceutical production.
TriMoxiVanc arrives already mixed into solution ready for draw and injection. It has a long stable shelf life with proven intraocular tissue compatibility.
TriMoxiVanc offers a significant advantage to the surgeon and ASC, with minimum distractions on the surgical field, compliance with Medicare requirements regarding compounding and single dosing in an ASC, with an acceptable cost while avoiding the obligation and documentation for patient counseling — and associated employee time costs — that eye drops and the associated compliance issues involve.

The injection procedure

The circulating nurse transfers the contents of the vial onto the sterile field directly into a tuberculin syringe drawn up by the surgical technician, which is placed on a 27-gauge Knolle hydrodissection cannula (Katena, Denville, N.J.). I inject approximately 0.2 ml, leaving some additional TriMoxiVanc available for a sub-tenons supplement in rare circumstances (Figure 1).
Figure 1: The surgeon performs the transzonular TriMoxi+Vancomycin injection using a 27-gauge hydrodissection cannula.
COURTESY: JAMES S. LEWIS, MD
During my viscoelastic placement prior to IOL implantation, in addition to inflating the capsular bag, I will add some extra viscoeleastic under the iris inferionasally. After I insert the IOL, I enter the Knolle cannula through the primary keratotomy wound and pass it along the surface of the capsule, with visible tenting until reaching the equator, upon which the capsular tenting ends, indicating arrival at the zonules. A slight posterior rotation of the cannula tip and depressive movement posterior — without any visible capsule movement — confirms proper placement (Figure 2).
Figure 2: Immediately after injecting the TriMoxi+Vancomycin mixture into the anterior vitreous through the zonules, the surgeon withdraws the cannula.
COURTESY: JEFFREY T. LIEGNER, MD
Sometimes I perceive a distinctive “pop” as the cannula tip penetrates a dense group of zonules. Other times there is no indication other than simply moving the cannula more posterior (deeper) without altering the visible capsule. My observational experience with ECP, including careful inspection of zonules, confirms the density of zonules is highly variable, yet the cannula weaves through the “wires” easily, never causing zonular injury or dehiscence.
Toric IOL alignment can be initially different, since the familiar red reflex used to visualize the alignment tic marks is replaced with a white reflex. Surgeons will quickly learn to visualize directly the tic marks on the optic more than seeing them in the red reflex.

Perfecting the injection technique

Most of the challenge in learning this technique, which is fundamentally a blind pass behind the iris, comes with watching and interpreting the appearance of the anterior capsule as the cannula slips radially outward and over it toward the zonules. The cannula easily passes into the zonules, and the injection should proceed slowly, filling the posterior space with added volume. About 75% of the time you see the plume of drug into the vitreous (Figure 3).
Figure 3: With the IOL and the TriMoxi+Vancomycin in their proper positions, some product is shown tracking toward the wound along the exit path of the cannula.
COURTESY OF JEFFREY T. LIEGNER, MD
With experience, even a small pupil with a post-phaco constricted iris does not prevent transzonular injection. My first attempts were 60% successful, and quickly became 100% after three or four surgery days of practice.
I have never wrenched or torn zonules in such a way as to create a perceived or clinically significant zonular dialysis. Even with vigilance for an unplanned patient-commanded eye movement, it just hasn’t happened. In the video I have posted, the zonules seem to take some stretching without breaking.

Clues and signs to watch

During injection, the posterior capsule and IOL complex will rise accordingly (a helpful clue), and viscoelastic will exit the main wound. If I inadvertently inject anterior to the zonules (not into the vitreous), TriMoxiVanc will either reflux into the visible anterior chamber, or remain hidden under the iris around the perimeter of the equator.
The viscoelastic will eject, replaced by the steroid-antibiotic mixture, but the capsule does not rise. You will discover this upon irrigation and aspiration (I/A) removal of viscoelastic, when the volume of mixture is swept out of the angle.
A small hyperopic eye already has a crowded anterior chamber, even after removal of the natural lens, and adding an additional 0.2 ml of volume to the vitreous — after phaco irrigation adds some vitreous hydration— will make the anterior chamber even more shallow. Entering the primary wound with the cannula at a flat angle (parallel to the iris) is better than having a steep inclining angle, since a flat orientation discourages rapid viscoelastic exiting the wound.
Only occasionally does an IFIS issue result in a iris prolapse problem (drawn up to the wound with viscoelastic egress) when the vitreous volume expands. If I anticipate it, I will pass the cannula through the paracentesis instead of the main wound to deliver the drugs. Even with my in-the-bag piggyback multifocal IOL/toric implants, the anterior chamber volume issue is rarely a problem after TriMoxi+Vancomycin injection.
The inferior vitreous as your TriMoxiVanc destination is preferable, as this creates any floaters visible in the superior field. This allows for a consistent verbal message pre- and postoperatively from staff reminding the patient what to look for and why.
You can perform viscoelastic removal after the TriMoxiVanc injection as usual, with a bit more caution while under the IOL with I/A. The surgeon’s view can be unfamiliar because the vitreous and red reflex may now be white with steroid (or fluctuating white depending on globe-microscope angle), and it takes some getting used to.
The large plume of opaque steroids sitting behind the IOL would suggest the vision postoperatively would be an issue, but the mix is never obstructing, and the floaters are always peripheral. About 80% of patients report the floaters on postoperative day one, but only 20% notice them at postoperative week one.

Additional tips

My first day of surgery using this technique, I probably succeeded 40% to 60% of the time in getting through the zonules (four of 10 injections remained anterior to the zonules).
With more experience, I quickly learned the clues and hand movement to get that cannula through the zonules. Now I’m 100%.
Steroid-induced IOP rise. We rarely experience steroid-induced pressure rises postoperatively (maybe 1:100 or less), since the triamcinolone dose is 4 mg or less. Note that I do concurrent ECP if I obtain high IOPs preoperatively or see glaucoma damage, or if the patient is on glaucoma medications, so perhaps this skews the IOP issue in my favor.
Postoperative steroids. Supplemental postoperative topical steroids are infrequent (some one in 15 cases). One of four postoperative ECP patients require additional steroids topically — either prednisolone 1% or fluorometholone 0.1%, usually TID and not for long, and are usually not a topic until after postoperative week one.
If the patient does need steroids — rarely — because inflammation exceeds the TriMoxiVanc dose, signs will be slight redness (ciliary flush), good and stable vision, some photophobia, absence of globe or lid swelling, and quiet anterior chamber. This distinguishes rebound inflammation from true endophthalmitis, and the conversation quickly results in a phoned-in topical steroid prescription.
Consent. I do not provide a separate consent for this injection, but some others do. I also advise patients about the reasons for doing this, and the benefits to the patient; all patients have favored the injection in lieu of drops. Unexpectedly, I have also found that many patients have “drop anxiety” and will proceed with surgery once they hear that drops will not be required.
Postoperative floaters. Floaters do occur in the superior visual field sometimes after surgery, causing anxiety the first couple of days, but these fade quickly, often by the first week. Patients just need reassurance.
If you inadvertently inject a bubble of air with the mixture, this will slosh around superiorly, and so the patients will see the moving bubble in their inferior visual field, and they will perceive that the IOL is loose and rolling around down below their vision; I’ve learned that if a bubble gets transferred into the vitreous, I tell the patient to expect to see it, just to avoid the panic phone call that evening.
Ciliary body hemorrhage. A few times I have overreached the zonules and bumped a ciliary tooth, eliciting a small ciliary body hemorrhage and subsequently some blood seen inferiorly on postoperative day one. This microhyphema fades quickly, without an IOP issue. Based on ECP observations, a wide variety of toothy ciliary bodies exist, and some just beg to be bumped even with excellent cannula technique.
By the way, I use Healon GV (14 mg/ml, Abbott Medical Optics, Santa Ana, Calif.) or Optivisc (12 mg/ml, Anika Therapeutics, Bedford, Mass.) And I try not to hyperinflate the anterior chamber prior to IOL implantation.
Operative notes. All my reports for intraocular procedures include this sentence: “TriMoxiVanc 0.2 ml preparation (triamcinolone 15 mg/ml with moxifloxacin 1 mg/ml, vancomycin 10 mg/ml) was instilled through the inferior zonules after IOL insertion, prior to viscoelastic removal.”
Use of NSAIDS. I rarely use NSAIDs, but will occasionally. The CME rate seems much reduced with directly applied steroid into the vitreous, and so my use of NSAID is more responsive than prophylaxis. If a complication occurs (open capsule, vitrectomy required), I will stain vitreous and clean up as usual, add more TriMoxiVanc at the end behind the capsule, and then supplement with NSAID drops at the postoperative week one visit just for added protection against CME.
Vitreous tongue and strands. Rarely, a tongue of vitreous will be drawn back with the cannula through the zonules coming from the inferionasal delivery site. Since this vitreous strand is furthest from the wounds, it does not incarcerate and subsequently retracts, not to be seen on postoperative day one.
I have also occasionally seen vitreous strands come around intact zonules not associated with the cannula’s penetration, and have seen tiny lens particles in the anterior vitreous for no apparent reason. Some zonules are dense and others are permeable, inviting reflux of the TriMoxiVanc from any equatorial area, letting lens chips get posterior, or allowing strands of vitreous to slip forward with irrigation.
Potential role for ECP. I use ECP (and you will see some interesting video of the injection sequence using the ECP camera) and so I am very familiar now with the highly variable appearance of ciliary processes, zonules and lens equator dimensions. This ECP experience is not needed to perform TriMoxiVanc injections, but it does add texture to what we never see, what we presume is going on under that iris.

Reimbursement issues

Without going into too much detail, I can imagine that future bureaucratic review will look at the economics and expenditures of individual surgeons, and judge their cost burden on the insurer for intraocular procedures.
Because medications are covered with Medicare Part D and most commercial insurance plans, the surgeon who avoids expensive prescription eye drops and instead uses an intraocular injection at the time of surgery will have both outstanding patient evaluations and less overall cost to the third-party payers for the covered cataract procedure. This might create a competitive advantage for some, as insurers consider closed panels and economic credentialing, depending on their local market. I mention this possibility as I cringe.
Some payers will cover the ASC’s injection of triamcinolone into the vitreous, depending on negotiated contract rates and bundled agreements (or out-of-network payment behavior), and the ASC bills J3300 for the steroid and 67028 for the intravitreal injection (non-Medicare only).
ASC pricing for TriMoxiVanc single-dose vial is still reasonable and I have been advised that it will continue to be. With the changes in compounding pharmacy regulations, the pathway to national distribution have changed, and the very expensive FDA process has been edited to suit a faster market introduction and lower delivery cost. I have not been given solid details on anticipated pricing, only that it will be quite affordable. OM
About the Author
Jeffrey T. Liegner, MD, is in private practice at Eye Care Northwest in Sparta, N.J. His e-mail address isliegner@embarqmail.com.
Disclosure: Dr. Liegner is a consultant to Imprimis. He has no other relevant conflicts to disclose.

Ophthalmology Management, Volume: 18 , Issue: May 2014, page(s): 46, 48, 50, 51, 53, 71
——
SAMPLE FOR WEBSITE:

Dropless Cataract Procedure

Redefines Cataract Surgery

In an effort to improve our patients’ experience with cataract surgery, Kremer Eye Center surgeons offer patients the option of having cataract surgery performed in such a way that most patients no longer need to take drops before or after surgery. This advanced procedure is called “Dropless Cataract Surgery.” In Dropless Cataract Surgery, a medicine called Tri-Moxi-Vanc* is placed in the eye at the time of surgery. The medication is absorbed by the eye over the next month, providing patients the benefit of antibiotics and anti-inflammatory medicines without needing drops.
Traditional cataract surgery requires the patient to use multiple eye drops before and after surgery, often up to 4 times a day for a month or more. In most cases, Dropless Cataract Surgery eliminates the need to apply over 400 drops in patients who are having cataract surgery on both eyes!
Studies have shown:
  • The Dropless Cataract method is very safe
  • Dropless Cataract Surgery allows us to eliminate all drops about 95% of the time
  • Reduced risk of infection and retinal swelling compared to patients using drops
  • Dramatically simplified postoperative regimen
  • Reduced chance of side effects from the eye drops
  • Can save patients over $300 in eye drop expenses
Should you and your surgeon decide to proceed with Dropless Cataract Surgery, drops before surgery will not be needed. Most patients will also not need drops after surgery; however, a small percentage may need to begin a steroid, called prednisolone, if inflammation develops. When you schedule your procedure, you will be given a prescription for prednisolone drops. Do not get this filled. If you develop inflammation after the surgery, your doctor may ask you to get the prescription filled and use this prednisolone from the pharmacy to help your eye heal.
As with all medications, Tri-Moxi-Vanc may have side effects, including blurred vision, floaters, and increased eye pressure. Please call us immediately if your eye develops increased redness, pain or discharge after surgery.

Have questions? Please call our Kremer Eye cataract specialists at 1-800-694-EYES (3937) to schedule your evaluation.

*Tri-Moxi-Vanc (combination of triamcinolone acetonide, moxifloxacin hydrochloride and vancomycin) is a compounded proprietary ophthalmic solution formulated by prescription for each patient.
—
TRI-MOXI
Triamcinolone acetonide and moxifloxacin hydrochloride
TRI-MOXI-VANC
Triamcinolone acetonide, moxifloxacin hydrochloride and vancomycin
LYOPHILIZED MYDRIATICS

Shopping Cart