New findings from a study published in the American Journal of Ophthalmology compared the treatment outcomes of intravitreal antibiotic-steroid (IVAS) injections with postoperative topical non-steroidal anti-inflammatory drug (NSAID) versus a standard triple-drop therapy (TDT) regimen following cataract surgery.
Give me some background.
The traditional TDT approach features patients instilling three topical drops for chemoprophylaxis against inflammation and infection:
- Antibiotics
- Corticosteroids
- NSAIDs
However, recently, a growing number of cataract surgeons have begun adopting an approach with perioperative intracameral injection of antibiotics and steroids.
Which leads us to …
A group of researchers sought to measure the treatment outcomes of IVAS (moxifloxacin-triamcinolone) with postoperative topical NSAID (IVAS-NSAID) compared to TDT.
Tell me more about the IVAS-NSAID regimen.
The IVAS-NSAID approach allows surgeons to inject a one-time dose of antibiotics and steroids directly into the vitreous, where drug activity is not limited by physiologic aqueous turnover, followed by a topical NSAID.
To note, a previous study found no difference in the following between IVAS and TDT cohorts:
- Best-corrected visual acuity (BCVA)
- Intraocular pressure (IOP)
- Persistent anterior chamber inflammation (PACI)
- Rebound inflammation (RI)
Also: higher rates of cystoid macular edema (CME) were reported in the IVAS group.
Consequently, as NSAIDS have been shown to decrease CME risk in high-risk eyes, the IVAS-NSAID regimen reduces the risk of CME.
Talk about existing issues with the TDT regimen.
Several barriers exist with the standard TDT regimen, such as:
- Cost
- Patient compliance with dosing regimens
- Incorrect usage of medications
- Physical difficulties with instilling drops
- Increased workload to manage questions from pharmacies and patients
Now talk about the study.
In this retrospective comparative cohort study, investigators analyzed the pre- and postoperative data of patients who underwent cataract surgery between 2017 and 2022 across three study centers.
They compared the non-infectious outcomes of 2,143 eyes (1,079 eyes IVAS-NSAID and 1,064 eyes TDT) at 1 week, 1 month, and 6 months following cataract surgery.
Exactly what kind of pre- and post op data was analyzed?
- Preoperative data→ patients’ age, iris color, previous medical history, and ocular history.
- Postperative data → BCVA, IOP, and the need for IOP-lowering medications.
What were the primary outcome measures?
The main outcome measures compared between both cohorts were postoperative complications, defined as:
- PACI
- Persistent corneal edema (PCE)
- RI
- CME
Findings?
Both BCVA and IOP measurements were similar between both groups at all time points.
Additionally, 11.6% of TDT eyes experienced postoperative complications, versus 6.5% of IVAS-NSAID eyes (p<0.001).
Anything else?
Of note, femtosecond laser-assisted cataract surgery (FLACS) was associated with increased rates of PCE in IVAS-NSAID eyes.
Further, eyes with dark irides had higher incidence of CME, PCE, and RI in the IVAS-NSAID group.
Expert opinion?
According to the study authors, “Surgeons may consider avoiding IVAS in patients with dark irides or using additional anti-inflammatory medications (e.g., additional injectable, implantable, or topical steroids) to supplement IVAS-NSAID.”
“These findings can aid surgeons in developing personalized postoperative regimens for the optimal use of IVAS-NSAID, based on patients’ comorbidities and demographic characteristics,” they added.
Take home.
Overall, the IVAS-NSAID regimen had similar postoperative outcomes and fewer complications in comparison to the TDT regimen.
Meaning?
These findings suggest that the IVAS-NSAID regimen could be considered a safe alternative to topical regimens in non-FLACS procedures and light irides patient populations.
Further, this approach could improve the postoperative experience for patients and decrease the costs and workload for eyecare practitioners.