Dropless cataract surgery increases the risk of prolonged steroid response postoperatively
Cataract surgery is one of the most common surgical procedures performed worldwide. Despite its safety and predictability, cataract surgery is continuously being improved to optimize post-operative outcomes. Dropless cataract surgery, in which a steroid depot is administered at the time of cataract surgery, has gained popularity as a technique that allows for less dependence on postoperative drops without compromising inflammation control or visual acuity outcomes. Surgical techniques for dropless cataract surgery are variable and include intravitreal or subconjunctival injections of triamcinolone, and sustained release formulations of dexamethasone as an intracanalicular insert or intraocular suspension. Dropless cataract surgery has the advantage of eliminating the need for costly and time-consuming eyedrop regimens known to result in poor adherence and undermine surgical results. The issue of adherence in the cataract patient population is further compounded by poor administration by individuals inexperienced with the use of conventional eyedrops.
The purpose of this study by Wu et al was to evaluate the incidence and risk factors of steroid-related IOP increase following uncomplicated dropless cataract surgery using subconjunctival triamcinolone compared with conventional cataract surgery using topical prednisolone.
Authors reviewed consecutive cataract surgery cases performed by a single surgeon to determine the likelihood of steroid response, defined as intraocular pressure (IOP) 50% above baseline or IOP > 24 mmHg postoperatively, excluding the first 72 hours. Main outcome measures were the proportion of eyes developing steroid response, risk factors for developing steroid response, and duration of steroid response.
Of the 150 dropless and 218 conventional cases, 26 eyes developed steroid response (15 dropless and 11 conventional cases [10% vs 5%, P=0.096]).
Risk factors for steroid response included dropless surgery (OR=2.43, 95% CI=1.03–6.02], P=0.046) and prior diagnosis of glaucoma (OR=7.18, 95% CI=2.66–19.22], P<0.001). Baseline IOP, age, sex, race, and axial length did not increase risk for steroid response. Of the eyes with steroid response, more dropless cases had an IOP elevation ≥30 days (9/15 eyes vs 1/11 eyes; P=0.008), including one patient with refractory IOP elevation in the dropless group who required urgent bilateral trabeculectomy for IOP control><0.001).
Baseline IOP, age, sex, race, and axial length did not increase risk for steroid response. Of the eyes with steroid response, more dropless cases had an IOP elevation ≥30 days (9/15 eyes vs 1/11 eyes; P=0.008), including one patient with refractory IOP elevation in the dropless group who required urgent bilateral trabeculectomy for IOP control.
In this study authors investigated the incidence and characteristics of steroid response following dropless cataract surgery with subconjunctival triamcinolone or conventional cataract surgery using topical prednisolone in a large patient cohort undergoing surgery with a single, highly experienced cataract surgeon. They found significantly higher mean IOP measurements at every postoperative time point in the dropless cataract surgery cohort compared to the conventional group. Furthermore, multivariate analysis demonstrated that dropless cataract surgery with subconjunctival triamcinolone was a significant predictor of steroid response, which occurred in 10% of eyes undergoing this procedure.
Dropless cataract surgery has become preferred by many anterior segment surgeons and patients given that it offers good postoperative control of inflammation while reducing drop dependence and potentially leads to more consistent outcomes after cataract surgery. However, caution must be exercised in light of possible increased rates of steroid response and greater likelihood of prolonged steroid response following steroid depot injection. Going forward, quality prospective studies will be needed to evaluate whether steroid depot dosage or location affect risk for IOP elevation following dropless cataract surgery. Nonetheless, patient selection prior to surgery will continue to be critical, and authors propose that patients suspicious for glaucoma or with a known diagnosis of glaucoma should be carefully identified and evaluated prior to dropless cataract surgery given their significant risk for IOP elevation and irreversible vision loss in response to steroids.
Source: Wu et al; Clinical Ophthalmology 2023:17 2803–2814
https://doi.org/10.2147/OPTH.S426200
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