Triamcinolone Acetonide Subconjunctival Injection as Stand-alone Inflammation Prophylaxis After Phacoemulsification Cataract Surgery

Shorstein NH, McCabe SE, Alavi M, Kwan ML, Chandra NS1
Industry support for this study: None

ABSTRACT SUMMARY

This large, retrospective cohort study compared the safety and efficacy of a single subconjunctival injection of triamcinolone acetonide (TA) as standalone antiinflammatory prophylaxis after routine phacoemulsification versus topical corticosteroid drops with or without NSAIDs for cataract surgery prophylaxis.

Within the Kaiser Permanente Northern California health system from 2018 through 2021, 69,832 eyes of eligible patients received either topical prednisolone acetate (with or without an NSAID) or a subconjunctival injection of TA (10 or 40 mg/mL) delivered in a low dose (1–3 mg) or a high dose (3.1–5 mg). All eyes received intracameral antibiotic prophylaxis. Event definitions and ascertainment windows were prespecified, and analyses were stratified by TA strength and dose to reflect common real-world practice patterns. The primary outcome measures were the association of postoperative macular edema and iritis diagnosed 15 to 120 days after surgery (effectiveness measures) and a glaucoma-related event (safety measure) between 15 days and 1 year after surgery.

Crude event rates were low overall but favored the injection group: macular edema 1.3% (topical) versus 0.8% (injection), iritis 0.8% (topical) versus 0.5% (injection), and glaucoma-related events 3.4% (topical) versus 2.8% (injection). In a multivariable analysis, all injection groups had lower odds ratios of macular edema than the topical group, and the TA 10 mg/mL high dose (approximately 4 mg) was associated with a statistically significant decrease in the odds of macular edema (odds ratio [OR], 0.64; P = .033). There was a trend of lower odds of a postoperative diagnosis of iritis in the high-strength groups, but statistical significance was not achieved. Compared with prednisolone acetate, the TA 10-mg/mL low-dose cohort showed lower odds (OR, 0.69; P = .001), the TA 10-mg/mL high-dose cohort showed similar odds (OR, 0.90; P = .40), and the TA 40-mg/mL low- and high-dose groups showed higher odds (OR, 1.46 [P = .062] and OR, 2.14 [P = .001], respectively) for postoperative glaucoma-related events. Endophthalmitis was rare across all groups; it was diagnosed on average in 0.04% of patients.

DISCUSSION

The analysis by Shorstein and colleagues supports injection-based, steroid-only inflammation prophylaxis as a practical alternative to traditional drops after uncomplicated cataract surgery. A subconjunctival injection of 10 mg/mL high-dose (4 mg) TA was associated with a lower risk of postoperative macular edema than either topical strategy without an observed penalty on safety, effectiveness, or glaucoma-related events. Caution is warranted, however, in young patients and those with a preoperative glaucoma-related diagnosis, compromised optic nerve, or high myopia. IOP monitoring remains an important consideration for patients at risk of a steroid response.

Study limitations included its observational, nonrandomized design, which allowed potential confounding from surgeon choice, case complexity, or patient factors. The cohort reflected routine, largely uncomplicated cataract cases within a single integrated system, which may limit generalizability of the study results to higher-risk eyes or different practice environments. Outcomes emphasized the early postoperative period for inflammation and the first postoperative year for glaucoma-related events; longer-term effects and patient-reported outcomes (comfort, convenience, adherence without drops) were not the focus of this analysis.

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Cost Analysis of Dropless Cataract Surgery Prophylaxis With Intracameral Antibiotics and Subconjunctival Steroids

Massa S, Smits DJ, Nguyen AT, et al2
Industry support for this study: R.P., Consultant (Apellis Pharmaceuticals)

ABSTRACT SUMMARY

This retrospective analysis compared the costs to patients and to health care systems of topical medication regimens and dropless, injection-based cataract surgery prophylaxis. US price inputs for topical ophthalmic drops were obtained from the Medical Expenditure Panel Survey (MEPS) 2020 dataset. The prices of dropless components—intracameral moxifloxacin plus subconjunctival TA—were obtained from pharmaceutical invoices and catalogs. Outcomes included the per-eye system cost (insurer plus patient payments) and patient out-of-pocket (OOP) cost. The national cost impact of converting to a dropless regimen was also modeled. Comparisons of system costs for individual topical medications and same-class dropless, injection-based medications used two-sided, one-sample t-tests.

MEPS contained 583 prophylactic topical ophthalmic purchases. For single-agent comparisons, the mean per-eye system costs for the least expensive topical steroid (prednisolone) and subconjunctival TA were $76.20 ±39.07 and $4.01, respectively (P < .001). For the injection-based regimen, the lowest-cost dropless package was $15.91 per eye charged to the health system with $0 OOP for the patient, whereas the lowest-cost topical regimen was $103.90 ±43.14 charged to the system and $43.64 ±37.32 OOP. This corresponds to an $87.99 (84.7%) reduction in system cost per eye and a $43.64 (100%) reduction in OOP cost relative to the lowest-cost topical regimen. Based on these results, Massa and colleagues estimated a potential national annual savings of up to $450 million in system costs and up to $225 million in OOP spending with an approach using an intracameral antibiotic and subconjunctival TA.

DISCUSSION

Massa and colleagues quantified a frequently cited benefit of dropless cataract surgery: economic efficiency. Consolidating postoperative prophylaxis into intracameral antibiotic administration and a single subconjunctival injection might reduce both direct patient costs and costs to the health care system.

Study limitations included the use of a cost model in which clinical outcomes were assumed to be equal between dropless and drop regimens. Published evidence supports the clinical efficacy and safety of dropless regimens for routine phacoemulsification,3,4 but a dropless regimen is not recommended for young patients, those with high myopia, or those at increased risk of glaucoma-related events. Cost savings for the health system were therefore likely overestimated. Additionally, the lowest-cost injection regimen that was included in this analysis was a multiuse vial injection regimen for multiple cases. The study therefore likely overestimated savings for health systems that prohibit multiuse vials, although these health systems could still realize a cost benefit because the study demonstrated statistically significant savings with single-use vials.

The study findings were price sensitive and depended on local drug acquisition prices and purchasing contracts, which might differ from the study’s MEPS and distributor inputs. This would alter total costs.

Finally, the model did not incorporate a quality of life analysis, and it omitted other cost-related factors such as travel and the cost of caregivers. The broader value and generalizability of the study’s results are therefore uncertain.

1. Shorstein NH, McCabe SE, Alavi M, Kwan ML, Chandra NS. Triamcinolone acetonide subconjunctival injection as stand-alone inflammation prophylaxis after phacoemulsification cataract surgery. Ophthalmology. 2024;131(10):1145-1156.

2. Massa S, Smits DJ, Nguyen AT, et al. Cost analysis of dropless cataract surgery prophylaxis with intracameral antibiotics and subconjunctival steroids. J Cataract Refract Surg. 2024;50(12):1215-1223.

3. Kuriakose RK, Cho S, Nassiri S, Hwang FS. Comparative outcomes of standard perioperative eye drops, intravitreal triamcinolone acetonide-moxifloxacin, and intracameral dexamethasone-moxifloxacin-ketorolac in cataract surgery. J Ophthalmol. 2022;2022:4857696.

4. Nassiri S, Hwang FS, Kim J, et al. Comparative analysis of intravitreal triamcinolone acetonide-moxifloxacin versus standard perioperative eyedrops in cataract surgery. J Cataract Refract Surg. 2019;45(6):760-765.