The joint Journal of Cataract & Refractive Surgery (JCRS)/JCRS Online Case Reports (JCRO) symposium kicked off with the presentation of several awards, announced by session moderators William Dupps, MD, PhD, and Sathish Srinivasan, MD.
JCRS Obstbaum Award for Full Length Article
Assessing ocular dominance: rethinking the current paradigm
Jay Pepose, MD, PhD
JCRS Mamalis Award for Laboratory Science Paper
Improvement of keratorefractive lenticule creation by application of a vortex beam in a UV femtosecond laser system
Christian Hammer, DSc, MME
Source: ASCRS
During the session, Ananth Sastry, MD, presented on cataract surgery in eyes with vitreomacular traction. He shared a case where a patient with vitreomacular traction was referred to him for cataract surgery clearance. His colleague had gotten a preop OCT of the macula, and Dr. Sastry said he recommends doing this because a lot of pathology can be invisible on regular exam.
If there is vitreomacular traction, what happens if we just phaco? Dr. Sastry said it might not be controlled and could have aggressive pulling of the vitreous. However, he noted there’s not a lot of evidence.
Dr. Sastry did a study that was a single-center, comparative retrospective clinical cohort study. The interventional group was VMT and cataract undergoing phaco, and the control group was VMT and cataract without any surgical intervention. Inclusion criteria were concurrent diagnosis of cataracts (any type and grade) and VMT (any type and grade). Exclusion criteria were diabetic retinopathy, AMD, RVO, active uveitis, previous retinal detachments, full thickness macular holes, and patients who underwent concurrent phaco/PPV at the time of CEIOL.
In terms of baseline demographics, Dr. Sastry said there were no significant differences between the two groups apart from age. Patients who underwent phaco tended to be a bit older. In terms of baseline ocular characteristics, patients in the phaco group had worse presenting VA because they had more significant cataracts. Otherwise, baseline retina characteristics were similar between the two groups.
There was no significant difference in rates of VMT release between the phaco group and those observed, Dr. Sastry said. He noted a longer time to release in the phaco group than in those observed. There was also no significant difference in rates of complications compared to VMT. There was a longer time to complication in the phaco group compared to those observed.
The study concluded that phaco does not induce or decrease the time to VMT release. Phaco does not change the rates of VMT-related complications, and intrinsic factors, such as age and adhesion diameter, play a larger role in both outcomes.
The second half of the session focused on JCRO, with moderators Craig See, MD, and Shameema Sikder, MD.
Bhargavee Gnanasambandam, MS, shared six unexpected cases of presumed endophthalmitis after a single day of dropless cataract surgery. One of the primary complaints patients have is the number of drops they have to take after cataract surgery. Dropless cataract surgery uses a mixture of two to three medications (vancomycin, triamcinolone acetonide, and/or moxifloxacin) that is injected intracamerally after phaco cataract surgery. This can eliminate the need for postop drops. Many surgeons have seen excellent results without significant complications, however, endophthalmitis is a rare complication of cataract surgery (affecting less than 1/5,000 patient). Dr. Gnanasambandam said multiple large studies have shown that dropless cataract surgery is a viable alternative to using multiple eye drops.
She shared a retrospective non-comparative case series of 6/12 patients with suspected endophthalmitis after dropless cataract surgery on a single day in October 2019. Uncomplicated dropless cataract surgery was performed on all patients using Tri-Moxi injection of 0.1 mL (triamcinolone acetonide and moxifloxacin, Imprimis), and all surgeries were completed by the same surgeon. Patients were followed in the postop period for a minimum of 3 months, and data was collected on patient demographics, visual acuity, treatment regimen, symptoms, and final outcomes.
Of 12 total patients in two ORs, there were six suspected of developing endophthalmitis.
One had no complicated past medical eye history and had gradually worsening blurry vision. This patient was ultimately diagnosed with endophthalmitis and was treated with tap and inject vancomycin and ceftazidime. The second patient had diabetic retinopathy history in both eyes and had presented with some blurry vision. This patient was diagnosed with TASS. The third patient had a history of Fuchs and presented with foreign body sensation. This patient was also diagnosed with TASS. The fourth patient had non-proliferative diabetic retinopathy and was the mildest of all the patients, with some blurry vision. This patient was also diagnosed with TASS.
The fifth patient was the most complicated, with a history of Fuchs and presentation with pain, tearing, redness, and foggy vision. This patient also had mild microcysts and was very inflamed, with worsening visual acuity. This patient was diagnosed with endophthalmitis and received tap and inject vancomycin and ceftazidime. This case was further complicated with a retained foreign body in the anterior chamber, which was removed.
The sixth patient had a history of posterior vitreous detachment and presented with foreign body sensation and floaters and mild corneal edema. This patient was diagnosed with endophthalmitis as well and had visual acuity that was 20/150 at presentation. After receiving antibiotic, the patient returned to normal.
In trying to understand why and how this happened on day 1, Dr. Gnanasambandam said it was ultimately suspected that the cause was likely due to the Tri-Moxi and not due to sterilization. It was discovered later that the FDA had released a compounding pharmacy alert for the pharmacy that was making this medication. There can be some concerns with compounding pharmacies because they don’t have the same regulations as the FDA, so there’s a higher risk.
While dropless cataract surgery has increased patient compliance and satisfaction, she said, further research into improving intracameral injections is key to reducing postoperative adverse events.
Nick Mamalis, MD, commented after the presentation, saying that the cases presented were consistent with TASS, and you want to be careful to differentiate between endophthalmitis and TASS. Dr. Mamalis noted that you always want to do a B-scan because very rarely does TASS spill over into the vitreous. The other thing is onset; it’s rare to get endophthalmitis that early. If you get it in 1–2 days, that’s a very aggressive bacteria. If it’s TASS, it won’t get worse, but with endophthalmitis, you could notice changes within the same day. From the data presented, he thinks the cases were TASS.
Editors’ note: Dr. Sastry and Dr. Gnanasambandam has no relevant financial disclosures.
