Vitreous gel, transparent by design, is virtually invisible under the operating microscope. Furthermore, it is particularly unwelcome in anterior segment surgery, because it makes surgery more difficult and is associated with a variety of serious intraoperative and postoperative complications such as a dropped lens fragment, corneal edema, cystoid macular edema, retinal detachment, and endophthalmitis.1-14 Fortunately, meticulous vitreous clean-up can reduce the incidence of many vision-threatening complications associated with vitreous loss.9 Until recently, however, surgeons had only indirect intraoperative clues to determine if vitreous gel were present in the anterior chamber and, if so, to what extent.
Triamcinolone acetonide (Kenalog; Bristol-Myers Squibb Company, New York, NY) has proven quite useful for visualizing vitreous in the anterior chamber15 and has become a routine part of our practice for complicated cataracts with large zonular dialyses. To date, we have performed more than 200 cases of triamcinolone-assisted anterior vitrectomy and have not seen a complication attributable to the agent. On the contrary, eyes receiving intracameral triamcinolone have a quieter postoperative course versus those in which the agent is not used.
PREPARATIONWe continue to prepare triamcinolone as originally described15 and remove the preservative by a sterile capture-and-wash technique. Our decision is based on a lack of data regarding the intracameral effects of benzyl alcohol, the preservative in Kenalog. Clearly, however, our original washing technique is a bit tedious, particularly when the encounter with vitreous is unexpected or the OR staff is unfamiliar with the technique.
It is therefore not surprising that one of the most common questions regarding intracameral triamcinolone is, “Can the preparation be simplified?” There are actually several options (and wide variation among surgeons) that range from using the agent directly out of the bottle to simple dilution. Others fill a syringe with triamcinolone, stand it inverted until the particles settle, express the vehicle, and resuspend the triamcinolone particles in the desired volume of BSS. In addition, compounding pharmacies sell preservative-free triamcinolone, but it has a limited shelf life.
TECHNIQUEWhen asked the best way to use triamcinolone, the answer is not to lose vitreous in the first place. The next best answer is to get lots of practice. Neither reply is practical for most surgeons, who instead must gain insight from the experience of others. Here at the Cincinnati Eye Institute, we typically withdraw 0.2mL of 40mg/mL triamcinolone acetonide, then wash and resuspend the agent in 2.0mL of BSS (10X dilution). Much higher concentrations tend to leave too much unbound triamcinolone in the anterior chamber, whereas a larger volume of a lower concentration of triamcinolone tends to distribute the particles more evenly.
Ideally, one injects the agent directly within the substance of the vitreous to obtain maximum visualization. Dusting the surface of the gel works, but only until one has removed the surface, at which point reinjection is necessary. Dr. Burk likes to swirl a little triamcinolone around the anterior chamber to get an overview of the situation. He then buries the cannula's tip within the gel and makes a very controlled injection. It is important to remember that, if the vitreous is near the wound and fluid comes out upon the injection, so will vitreous. Inserting the cannula through the paracentesis often avoids such reflux. Vitrectomy should be performed with a high cutting rate, a low aspiration rate, and separate irrigation. Although not always needed, a pars plana approach can be quite helpful, particularly for vitreous at the site of the corneal incision (Figure 1).
ALTERNATIVESRealizing that the vitreous gel will capture and hold nearly any particulate matter, some groups are evaluating alternative techniques of vitreous identification. The most notable is 11-deoxycortisol, a steroid precursor without glucocorticoid effects.16
Nonetheless, we prefer triamcinolone acetonide because it is readily available, is nontoxic,17-19 and has a 25-year track record for intraocular use since it was first described in 1980 by Tano et al.20 In addition, one should not underestimate the role of intracameral triamcinolone in stabilizing the blood-aqueous barrier and minimizing inflammation on postoperative day one in complicated anterior segment cases.
QUESTIONSTo date, two questions about triamcinolone-assisted vitrectomy are unresolved. As mentioned earlier, the first regards the method of preparation and the effects of the benzyl alcohol preservative. The use of preservative-free or washed triamcinolone makes intuitive sense, but we are unaware of any evidence suggesting that the removal of the benzyl alcohol preservative is helpful or necessary.
The second question relates to the probability of steroid-induced glaucoma. It is well known that our vitreoretinal colleagues observe increased IOP after the depot injection of an intraocular steroid. Indeed, the amount of steroid deposited correlates with the percentage of patients experiencing elevated IOPs and with the severity of the rise in pressure.
Although it is certainly possible that an eye will develop glaucoma after undergoing triamcinolone-assisted anterior vitrectomy, we have not observed this complication. Furthermore, the risk of steroid-induced glaucoma seems to be minimal when the surgeon uses a small amount of triamcinolone and then removes most of it along with the vitreous gel that was identified. In summary, we have found triamcinolone acetonide to be safe and quite useful for identifying and removing vitreous.
Scott E. Burk, MD, PhD, is Clinical Ophthalmologist at the Cincinnati Eye Institute and Volunteer Faculty for the Department of Ophthalmology, University of Cincinnati College of Medicine. He states that he holds no financial interest in any product or company mentioned herein. Dr. Burk may be reached at (513) 984-5133; sburk@cincinnatieye.com.Robert J. Cionni, MD, is Medical Director of the Cincinnati Eye Institute. He states that he holds no financial interest in any product or company mentioned herein. Dr. Cionni may be reached at (513) 984-5133; rcionni@cincinnatieye.com.
Andrea P. Da Mata, MD, is Research Ophthalmologist at the Cincinnati Eye Institute. She states that she holds no financial interest in any product or company mentioned herein. Dr. Da Mata may be reached at (513) 984-5133; andreadamata@hotmail.com.
Robert H. Osher, MD, is a professor in the Department of Ophthalmology at the University of Cincinnati College of Medicine and is Medical Director Emeritus at the Cincinnati Eye Institute. Dr. Osher is also the founder and editor of the Video Journal of Cataract and Refractive Surgery. He states that he holds no financial interest in any product or company mentioned herein. Dr. Osher may be reached at (513) 984-5133; rhosher@cincinnatieye.com.
1. Shah DP, Krishnan AA, Albanis CV, et al. Visual acuity outcomes following vitreous loss in glaucoma and diabetic patients. Eye. 2002;16:271-274.
2. Tan JH, Karwatowski WS. Phacoemulsification cataract surgery and unplanned anterior vitrectomy—is it bad news? Eye. 2002;16:117-120.
3. Ionides A, Minassian D, Tuft S. Visual outcome following posterior capsule rupture during cataract surgery. Br J Ophthalmol. 2001;85:222-224.
4. Chitkara DK, Smerdon DL. Risk factors, complications, and results in extracapsular cataract extraction. J Cataract Refract Surg. 1997;23:570-574.
5. Berrod JP, Sautiere B, Rozot P, Raspiller A. Retinal detachment after cataract surgery. Int Ophthalmol. 1996-1997;20:301-308.
6. Frost NA, Sparrow JM, Strong NP, Rosenthal AR. Vitreous loss in planned extracapsular cataract extraction does lead to a poorer visual outcome. Eye. 1995;9(pt 4):446-451.
7. Banker AS, Freeman WR. Retinal detachment. Ophthalmol Clin North Am. 2001;14:
695-704.
8. Drolsum L, Haaskjold E. Causes of decreased visual acuity after cataract extraction. J Cataract Refract Surg. 1995;21:59-63.
9. Spigelman AV, Lindstrom RL, Nichols BD, Lindquist TD. Visual results following vitreous loss and primary lens implantation. J Cataract Refract Surg. 1989;15:201-204.
10. Balent A, Civerchia LL, Mohamadi P. Visual outcome of cataract extraction and lens implantation complicated by vitreous loss. J Cataract Refract Surg. 1988;14:158-160.
11. Berger BB, Zweig KO, Peyman GA. Vitreous loss managed by anterior vitrectomy. Long-term follow-up of 59 cases. Arch Ophthalmol. 1980;98:1245-1247.
12. Kanski JJ, Ramsay JH. Vitrectomy techniques in the management of complications in cataract surgery. Trans Ophthalmol Soc UK. 1980;100(pt 1):216-218.
13. Mamo JG. Late effects of vitreous loss. Ann Ophthalmol. 1974;6:935-941.
14. Ruiz RS, Teeters VW. The vitreous wick syndrome. A late complication following cataract extraction. Am J Ophthalmol. 1970;70:483-490.
15. Burk SE, Da Mata AP, Snyder ME, et al. Visualizing vitreous using Kenalog suspension. J Cataract Refract Surg. 2003;29:645-651.
16. Kaji Y, Hiraoka T, Okamoto F, et al. Visualizing the vitreous body in the anterior chamber using 11-deoxycortisol after posterior capsule rupture in an animal model. Ophthalmology. 2004;111:1334-1339.
17. McCuen BW 2nd, Bessler M, Tano Y, et al. The lack of toxicity of intravitreally administered triamcinolone acetonide. Am J Ophthalmol. 1981;91:785-788.
18. Hida T, Chandler D, Arena JE, Machemer R. Experimental and clinical observations of the intraocular toxicity of commercial corticosteroid preparations. Am J Ophthalmol. 1986;101:190-195.
19. Young S, Larkin G, Branley M, Lightman S. Safety and efficacy of intravitreal triamcinolone for cystoid macular oedema in uveitis. Clin Experiment Ophthalmol. 2001; 29:2-6.
20. Tano Y, Chandler D, Machemer R. Treatment of intraocular proliferation with intravitreal injection of triamcinolone acetonide. Am J Ophthalmol. 1980;90:810-816.