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Dr. Mark Siegel, MD FAAO

Health, Sea Island Ophthalmology, eyes

Take care when watching eclipse of the sun

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By Dr. Mark Siegel

On Monday, Aug. 21, the entire United States will see a partial eclipse of the sun. Parts of 11 states will experience a total solar eclipse, including South Carolina. 

If you get a chance to see it, make sure to take care of your vision during the eclipse. 

To see a complete eclipse of the sun, you need to be in the right place. The area that will have a complete eclipse – the path of totality – is only 70 miles wide and will move across the continent very quickly. Plan now for where you want to be. You may want a backup plan in case weather gets in the way of your view of the sky. Beaufort County is NOT in the path of totality, therefore we will only see a partial eclipse.

The only time it is safe to look directly at the sun is when it is completely covered by the moon during the totality phase of the eclipse. You must protect your eyes during the rest of the eclipse or you could damage your retina, possibly causing blindness.

Areas outside the path of totality will have a partial eclipse. Only part of the sun is blocked even at the peak of the eclipse. In those areas, there is no safe time to look at the sun with the naked eye. 

You must protect your eyes while watching the entire eclipse. This would include those of us in Beaufort County.

A truly awe-inspiring event, a solar eclipse is when the moon blocks any part of the sun from our view. The bright face of the sun is covered gradually by the moon during a partial eclipse, lasting a few hours. 

During the brief period of a total eclipse when the moon fully covers the sun (only a couple of minutes), the light of day gives way to a deep twilight sky. The sun’s outer atmosphere (called the solar corona) gradually appears, glowing like a halo around the moon in front of it. Bright stars and planets become more visible in the sky.

Watching a solar eclipse is a memorable experience, but looking directly at the sun can seriously damage your eyes. Staring at the sun for even a short time without wearing the right eye protection can damage your retina permanently. It can even cause blindness, called solar retinopathy.

There is only one safe way to look directly at the sun, whether during an eclipse or not: through special-purpose solar filters. These solar filters are used in “eclipse glasses” or in hand-held solar viewers. They must meet a very specific worldwide standard known as ISO 12312-2.

Keep in mind that ordinary sunglasses, even very dark ones, or homemade filters are not safe for looking at the sun.

Here are some steps to follow for safely watching a solar eclipse:

• Carefully look at your solar filter or eclipse glasses before using them. If you see any scratches or damage, do not use them.

• Always read and follow all directions that come with the solar filter or eclipse glasses. Help children to be sure they use handheld solar viewers and eclipse glasses correctly.

• Before looking up at the bright sun, stand still and cover your eyes with your eclipse glasses or solar viewer. After glancing at the sun, turn away and remove your filter — do not remove it while looking at the sun.

• The only time that you can look at the sun without a solar viewer is during a total eclipse. When the moon completely covers the sun’s bright face and it suddenly gets dark, you can remove your solar filter to watch this unique experience. Then, as soon as the bright sun begins to reappear very slightly, immediately use your solar viewer again to watch the remaining partial phase of the eclipse.

• Never look at the uneclipsed or partially eclipsed sun through an unfiltered camera, telescope, binoculars or other similar devices. This is important even if you are wearing eclipse glasses or holding a solar viewer at the same time. The intense solar rays coming through these devices will damage the solar filter and your eyes.

• Talk with an expert astronomer if you want to use a special solar filter with a camera, a telescope, binoculars or any other optical device.

For information about where to get the proper eyewear or handheld viewers, check out the American Astronomical Society. 

NASA will have a live stream of the eclipse that can be watched online, which is exactly what we’ll be doing.

Dr. Mark Siegel is the medical director at Sea Island Ophthalmology at 111 High Tide Drive (off Midtown Drive near Low Country Medical Group). Visit www.seaislandophthalmology.com.

Enjoy summer sun, but protect eyes from UV rays

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By Dr. Mark Siegel

We all use sunscreen to protect our skin, but don’t forget to protect your eyes as well. 

Summertime means more time spent outdoors, and studies show that exposure to bright sunlight may increase the risk of developing cataracts and growths on the eye, including cancer. 

The same risk applies when using tanning beds, so be sure to protect your eyes from indoor UV light as well. Sunlight reflected off sand and water can cause photokeratitis, the condition responsible for snow blindness, so beach- and pool-goers take note.

UV radiation, whether from natural sunlight or indoor artificial rays, can damage the eye’s surface tissues as well as the cornea and lens.

Unfortunately, many people are unaware of the dangers UV light can pose. 

By wearing UV-blocking sunglasses, you can enjoy the summer safely while lowering your risk for potentially blinding eye diseases and tumors. 

It is important to start wearing proper eye protection at an early age to protect your eyes from years of ultraviolet exposure.

According to a national Sun Safety Survey conducted by the American Academy of Ophthalmology, only about half of people who wear sunglasses say they check the UV rating before buying. The good news is that you can easily protect yourself. 

In order to be eye smart in the sun, the American Academy of Ophthalmology recommends the following:

• Wear sunglasses labeled “100 percent UV protection”: Use only glasses that block both UV-A and UV-B rays and that are labeled either UV400 or 100 percent UV protection.

• Choose wraparound styles so that the sun’s rays can’t enter from the side.

• If you wear UV-blocking contact lenses, you’ll still need sunglasses.

• Wear a hat along with your sunglasses; broad-brimmed hats are best.

• Remember the kids: It’s best to keep children out of direct sunlight during the middle of the day. Make sure they wear sunglasses and hats whenever they are in the sun.

• Know that clouds don’t block UV light: The sun’s rays can pass through haze and clouds. Sun damage to the eyes can occur any time of year, not just in summer.

• Be extra careful in UV-intense conditions: Sunlight is strongest mid-day to early afternoon, at higher altitudes and when reflected off of water, ice or snow.

By embracing these simple tips you and your family can enjoy the summer sun safely while protecting your vision.

Dr. Mark Siegel is the medical director at Sea Island Ophthalmology at 111 High Tide Drive (off Midtown Drive near Low Country Medical Group). Visit www.seaislandophthalmology.com.

Avoid unlicensed clinics offering unapproved stem cell therapy

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By Dr. Mark S. Siegel

Stem cell therapies are getting headlines for their potential to cure diseases, including those that affect vision. But an important message is missing: the therapies are not yet proven to be safe and effective for your eyes.

Stem cell treatments appear to offer hope to people with few options to recover vision. This includes people with forms of age-related macular degeneration (AMD), retinitis pigmentosa (RP) and Stargardt disease. 

Some clinics across the United States offer “stem cell therapy” to people outside of clinical trials. But the U.S. Food and Drug Administration (FDA) has not approved the treatments they offer. These treatments often use unproven products that may be ineffective or dangerous. These products may carry serious risks, including tumor growth.

Questions to ask

It is important that you know that there are no stem cell products approved by the FDA for eye disease right now. 

If you want stem cell therapy, look for a clinical trial and discuss the matter with your ophthalmologist. A clinic should not expect you to pay thousands of dollars for an unproven, unapproved therapy. Your health insurance will not cover the cost of an unapproved treatment.

Before agreeing to a stem cell treatment, ask:

• Is the stem cell treatment approved by the FDA?

• Is the stem cell treatment part of an FDA-approved clinical trial?

• Is the stem cell treatment covered by your health insurance?

It is frustrating and frightening to face the loss of vision while waiting for potential treatments. However, choosing to pursue an unproven treatment in an unlicensed clinic is an unacceptable risk to your vision and your overall health.

Dr. Mark S. Siegel is the medical director at Sea Island Ophthalmology on Ribaut Road. Visit www.seaislandophthalmology.com.

Study: Alzheimer’s patients benefit from eye surgery

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By Dr. Mark S. Siegel

Researchers at Tenon Hospital in Paris have found that patients with mild Alzheimer’s disease whose vision improved after cataract surgery also showed improvement in cognitive ability, mood, sleep patterns and other behaviors.

This is the first study to specifically assess whether cataract surgery could benefit Alzheimer’s patients, although earlier research had shown that poor vision is related to impaired mood and thinking skills in older people and that cataract surgery could improve their quality of life. 

Thirty-eight patients, average age 85 and all exhibiting mild dementia due to Alzheimer’s disease, completed the study. 

All participants had debilitating cataract in at least one eye and were appropriately treated with standard cataract surgery and implantation of intraocular lenses, which replace the eyes’ natural lenses in order to provide vision correction. 

After surgery, distance and near vision improved dramatically in all but one of the Alzheimer’s patients.

A neuropsychologist assessed the Alzheimer’s patients for mood and depression, behavior, ability to function independently and cognitive abilities at one month before and three months after cataract surgery. 

Cognitive status, the ability to perceive, understand and respond appropriately to one’s surroundings, improved in 25 percent of patients. Depression was relieved in many of them, and the level of improvement was similar to what commonly occurs after cataract surgery in elderly people who do not have dementia. 

No changes were found in patients’ level of autonomy, that is, their ability to function independently.

Sleep patterns improved and nighttime behavior problems decreased in most study patients. 

Other studies have shown that when cataracts are removed, levels of the sleep-regulating hormone melatonin become normalized. Dr. Girard notes that this may have been a key factor in the Alzheimer’s patients’ improved sleep patterns.

Since removing cataracts can improve the ability of patients with Alzheimer’s disease to function, improve their mood, cognition and sleep patterns, then this is another means to help those we love with this debilitating disease.

Dr. Mark S. Siegel is the medical director at Sea Island Ophthalmology on Ribaut Road in Beaufort. 

Visit www.seaislandophthalmology.com for more information.

New treatments for dry age-related macular degeneration

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By Dr. Mark S. Siegel

Macular degeneration is currently the leading cause of visual impairment in the U.S.

Breakthrough treatment with anti-VEGF eye injections such as Avastin (bevacizumab, Genentech), Lucentis (ranibizumab, Genentech) and Eylea (aflibercept, Regeneron) has almost arrested the progression of the wet form of the disease.

However, almost 80 percent of people diagnosed with age-related macular degeneration (AMD) have the non-neovascular (dry) or atrophic subtypes.

The American Academy of Ophthalmology notes that the most advanced form of non-neovascular AMD, known as geographic atrophy (GA), can occur as early as in intermediate AMD or (more typically) in advanced AMD.

Estimates predict advanced AMD will impact as many as 3 million people in at least one eye by 2020.

The growing number of aging Americans underscores the need for treatments that can prevent progression of and/or treat advanced AMD.

Trials underway 

Surprisingly, no treatments are currently available for the prevention of GA. Evidence from the Age-Related Eye Disease Study (AREDS) suggests antioxidant vitamin and mineral supplementation may help prevent the progression to neovascular AMD, but the study failed to show that vitamin supplementation decreased progression to geographic atrophy.

Even in AREDS2, when beta-carotene was replaced with lutein/zeaxanthin to decrease the risk of lung cancer, the new formulation also failed to show decreased progression to GA.

Clinical studies are underway to further elucidate and understand the mechanisms of dry AMD and to evaluate new therapeutics directed at slowing the progression.

There are currently two large phase 3 trials underway for the treatment of GA. The FILLY study assesses the safety, tolerability and evidence of activity of multiple intravitreal (IVT) injections of APL-2 (Apellis Pharmaceuticals) for patients with GA. The second is a multicenter, randomized, double-masked, sham-controlled study to investigate IVT injections of lampalizumab in patients with GA.

The discovery of complement byproducts in drusen led to associations between complement dysregulation and AMD.

Thus, several researchers are evaluating the complement cascade as a clinical therapeutic target for non-neovascular AMD.

Factor D is considered a critical early component of the alternative pathway that involves complement factor H. Factor D is an upstream of factor B and other AMD-associated proteins, making it a potential powerful target for treatment.

Anti-inflammatory agents under development include lampalizumab, fluocinolone, glatiramer acetate, sirolimus, eculizumab and ARC-1905.

These are but the tip of the iceberg of compounds under development for advanced AMD or GA.

Visual cycle inhibitors are among those in latter-stage development and include fenretinide, ACU-4429 and ALK-001.

These compounds down-regulate the visual cycle to decrease the accumulation of the toxic waste products of retinal metabolism. Amyloid-beta has been found in drusen, and RN6G and GSK933776 are in development to regulate amyloid-beta accumulation.

Neuroprotective drugs are also under development, including UF-021, ciliary neurotrophic factor and brimonidine tartrate intravitreal implant.

Topical agents such as MC-1101 are attempting to slow AMD by increasing choroidal perfusion.

Stem cell therapies including HuCNS-SC and MA09-hRPE are also under investigation as potential treatments for GA.

At this point, it is too early to tell which — if any — of these treatments will become a standard of care.

Dr. Mark S. Siegel is the Medical Director at Sea Island Ophthalmology on Ribaut Road in Beaufort. 

Visit www.seaislandophthalmology.com for more information.

New class of glaucoma drugs in development

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By Dr. Mark S. Siegel

Primary Open Angle Glaucoma is the most common type of glaucoma. An increase in eye pressure, intraocular pressure (IOP), occurs slowly over time, leading to vision loss. Higher IOP is thought to be the result of changes in the eye that lead to an obstruction in the outflow of fluid, called aqueous humor.

Large clinical studies have shown that, with reduction in IOP, optic nerve damage and progressive visual loss can be slowed or minimized.

Glaucoma therapies

Current drug treatments are directed towards lowering IOP. Treatments to reduce IOP rely on topical eye drop medications, laser and or conventional surgery.

Many patients require more than one drug to control IOP, and despite effective current therapies, they don’t work for all patients.

Current glaucoma medications reduce IOP by either reducing the production of fluid in the eye, or by increasing its outflow. Prostaglandins, which increase outflow, are now the most prescribed glaucoma treatment worldwide.

Glaucoma drugs

A new class of glaucoma drugs promises to act specifically on the eye’s drainage canals, called the trabecular meshwork, a main outflow and blockage site in glaucoma.

Rho kinase (ROCK) inhibitors target cells in the trabecular meshwork to enhance aqueous humor outflow. Aqueous humor is a clear fluid that maintains the intraocular pressure.

In research models of glaucoma, ROCK inhibitors have been shown to reduce cellular “stiffness” and enhance outflow through the trabecular meshwork, thereby reducing IOP. No drugs currently on the market enhance the eye’s fluid outflow in this way. Therefore this is a novel and unique target and approach to lowering IOP.

ROCK inhibitors are not yet approved and available for glaucoma patients.

Two U.S. companies, Aerie and Altheos, are currently in clinical research development with topical ROCK inhibitors to lower IOP.

Research data has shown that ROCK inhibition has the potential to offer neuroprotective and anti-inflammatory effects as well as enhance blood flow to the optic nerve, all of which could benefit glaucoma patients.

The ophthalmic community looks forward to and awaits the clinical research data as it becomes available for this potentially exciting class of drug compounds.

Can fish oil help dry eye?

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By Dr. Mark S. Siegel

While artificial tears or ointments are a common treatment for dry eye, studies suggest consuming omega-3 fatty acid supplements may also provide relief.

Omega-3 oils appear to improve function in the eye’s meibomian glands, which produce the oily part of tears. Improved function of those glands can ease dry eye symptoms.

Dry eye becomes more common as a person ages. The problem develops when the eye cannot maintain a healthy coating of tears. Dry eye can be caused by hormonal changes brought on by menopause. There are a number of other causes, including a dry environment or workplace (such as wind or air conditioning), sun exposure, smoking or secondhand smoke exposure and many medications.

The National Eye Institute notes that in some patients with dry eye, supplements or dietary sources of omega-3 fatty acids (such as tuna fish) may decrease symptoms of irritation.

Many studies have shown that the omega-3s in fish oil are believed to reduce inflammation. If inflammation of the eyelids or surfaces of the eye worsens dry eye, it makes sense that a supplement could help the problem.

Since dry eye is pretty complex, and there is no cure, it seems reasonable that by treating the inflammation, one can improve some of the symptoms.

A study of more than 32,000 women from the Women’s Health Study published in 2005 found those who consumed the most omega-3 fats from fish had a 17 percent lower risk of dry eye, compared with women who ate little or no seafood. More recently, a study in the International Journal of Ophthalmology concluded omega-3 fatty acids have a definite role for dry eye syndrome.

Omega-3 oils may also help in the treatment of other eye diseases. The oils may reduce growth of abnormal blood vessels that occur in age-related macular degeneration and other retinal vascularization diseases.

Talk to your doctor to find out whether omega-3 supplements are right for you.

Protect your eyes from sun damage

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The days are longer, the sun is hotter, the beach beckons and out comes the sunscreen.

But summer revelers looking forward to sizzling hot fun in the sun shouldn’t overlook their eyes when it comes to protecting themselves from damaging ultraviolet rays.

In support of UV Safety Month in July, Sea Island Ophthalmology joins the American Academy of Ophthalmology in sharing information on how to keep eyes safe from sun damage.

Excess sun exposure can put people at risk of serious short-term and long-term eye problems. If eyes are exposed to strong sunlight for too long without protection, UV rays can burn the cornea and cause temporary blindness in a matter of hours. Long-term sun exposure has also been linked to an increased risk of cataracts, age-related macular degeneration, cancer and growths on or near the eye.

Here are five things people can do to cut their risk of eye damage from the sun:

• Wear the right sunglasses: Look for those labeled “UV400” or “100 percent UV protection” when buying sunglasses. Less costly sunglasses with this label can be just as effective as the expensive kind. Darkness or color doesn’t indicate strength of UV protection. UV rays can go through clouds, so wear sunglasses even on overcast days. And while contact lenses and lens implants may offer some benefit, they cannot protect the entire eye area from burning rays.

• Don’t stare at the sun: Sun worshippers take note: directly gazing at the sun can burn holes in the retina, the light-sensitive layer of cells in the back of the eye needed for central vision. This condition is called solar retinopathy. While rare, the damage is irreversible.

• Check your medication labels: One in three adults uses medication that could make the eyes more vulnerable to UV ray damage, according to a sun safety survey by the academy. These include certain antibiotics, birth control and estrogen pills, and psoriasis treatments containing psoralen. Check the labels on your prescriptions to see if they cause photosensitivity. If so, make sure to protect your skin and eyes or avoid sun exposure when possible.

• Put a lid on it: In addition to shades, consider wearing a hat with a broad brim. They have been shown to significantly cut exposure to harmful rays. Don’t forget the sunscreen!

• Don’t drive without UV eye protection: Don’t assume that car windows are protecting you from UV light. A recent study found that side windows blocked only 71 percent of rays, compared to 96 percent in the windshield.  Only 14 percent of side windows provided a high enough level of protection, the researchers found. So when you buckle up, make sure you are wearing glasses or sunglasses with the right UV protection.

At the end of the day, you want to retain fond memories and experiences during summer celebration, not skin cancer and blinding eye disease.

For more information, visit www.seaislandophthalmology.com.

Vitamin see: foods rich in vitamin C may help slow cataracts

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By Dr. Mark S. Siegel

What do grapefruit, broccoli and strawberries have in common?

They are foods loaded with vitamin C, which could help slow cataract progression, according to a British study.

Cataracts are a clouding of the eye’s lens that happens naturally with age. The condition is the leading cause of blindness in the world, according to the World Health Organization.

Researchers from King’s College London examined data from more than 1,000 pairs of female twins to see what factors may help keep cataracts at bay. They tracked intake of vitamin C and other nutrients from food and supplements. They also recorded how opaque the subjects’ lenses were at around age 60, with a follow-up on 324 sets of twins about 10 years later.

Women who reported consuming more vitamin C-rich foods had a 33 percent risk reduction of cataract progression over the decade, according to the study. Their lenses overall were more clear.

Although we cannot totally avoid developing cataracts, we may be able to delay their onset and keep them from worsening significantly by eating a diet rich in vitamin C. The researchers noted that the findings only pertain to vitamins consumed through food and not supplements.

Vitamin C is a powerful antioxidant. The fluid inside the eyeball is normally high in a compound similar to vitamin C, which helps prevent oxidation that results in a clouded lens. Scientists believe more vitamin C in the diet may increase the amount present around the lens, providing extra protection.

Because the study was done in twins, the team was also able to calculate how much of a role genetics versus environmental factors play in cataract progression. While environmental factors, such as diet, accounted for 65 percent, genetic factors only accounted for 35, indicating that diet and lifestyle may outweigh genetics.

The study, “Genetic and Dietary Factors Influencing the Progression of Nuclear Cataract“ will be published this June in Ophthalmology, the official journal of the American Academy of Ophthalmology.

Dropless Cataract Surgery: What are the potential risks?

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By Dr. Mark S. Siegel

Cataract surgery continues to evolve, with microincisional clear corneal incisions, femtosecond lasers, new imaging modalities, and improved lens implants. However, the published literature is having trouble keeping up with clinical practice. Despite the ongoing change, one concern remains constant: endophthalmitis (infection) prophylaxis. The use of perioperative povidone-iodine, a lid speculum, and drape with isolation of lids and lashes, and sterile preparation, is effective in limiting the incidence of endophthalmitis after cataract surgery.

The recent advent of “dropless” cataract surgery via transzonular ocular injections of TriMoxi or TriMoxiVanc, offers another option of infection prophylaxis. As some cataract surgeons consider adopting dropless cataract surgery it is important to balance the potential complications and risks involved with this technique.

These combinations of antibiotics and steroids are delivered to the anterior vitreous (jelly that fills the back of the eye) by injection through the zonules (tiny spider web-like ligaments that anchor the lens to the wall of the eye). This is intended to mitigate the need for post-operative topical drops. Drops can be costly, can irritate the surface of the eye, can be difficult for some patients to administer and can be burdensome to prescribers. Though post-operative drops are less than ideal, this new mode of dropless infection prophylaxis contains some inherent risks.

A clear concern is compounding errors. There have been reports of dilutional errors with intraocular antibiotics that have resulted in complications including macular swelling, retinal detachment, macular infarction, toxic anterior segment syndrome (severe inflammation) and a large outbreak of Fusarium endophthalmitis.

The pharmacokinetics of TriMoxi(+/-) Vanc is unclear when placed in the anterior vitreous. These antibiotics have the shortest half-life of current intravitreal antibiotics being used (1.7 hours). Vancomycin has a half-life of 25.1 hours. Routine topical antibiotics are able to produce concentrations inside the eye for a week post-operatively. While one European study showed decreased rates of endophthalmitis with injected antibiotics, all arms of the study used 6 days of topical postoperative antibiotics! The question remains: is the duration of coverage with injected antibiotics without topical antibiotics adequate?

Antibiotic resistance is another consideration when using TriMoxi. Emerging resistance has been identified. A recent review found resistance rates to moxifloxacin has increased from 21% in 1995 to 62% in 2014.

The use of prophylactic vancomycin in TriMoxiVanc during routine cataract surgery is controversial. The Centers for Disease Control issued guidelines in 1995 specifically discouraging the use of vancomycin in routine surgical prophylaxis because of increasing bacterial resistance. The risk of fueling the emerging resistance to vancomycin for an unproven practice is worrisome. Given that there are more than 3 million cataract surgeries performed in the United States each year, exposure of the ocular surface to low doses of vancomycin could result in an increase in vancomycin resistant bacteria.

Another unknown is the risk of steroid-induced ocular hypertension (elevated eye pressure) associated with TriMoxi(+/-) Vanc. It is well known that topical steroids can induce ocular hypertension, but drops are easily discontinued, whereas injected intraocular steroids are not. Currently there is a paucity of literature addressing transzonular triamcinolone (the steroid component in TriMoxi) and its associated ocular hypertension risk. Furthermore, the use of triamcinolone leaves patients with obscured vision and floaters for the first week or more. Patient complaints of foggy vision postoperatively have led some cataract surgeons to discontinue the product. Many randomized trials show that topical nonsteroidal anti-inflammatory drugs (NSAIDS) are superior to topical steroids in reducing post-operative macular swelling after cataract surgery. Thus, regardless of the intraocular steroid and antibiotic used, it is likely that a topical NSAID will need to be prescribed.

Technical and mechanical issues must be considered in addition to issues of bacterial resistance, compounding risks, steroid-induced elevated eye pressure, and post-operative foggy vision. In patients with lens zonular weakness (pseudoexfoliation), intraocular lens (IOL) decentration or dislocation may occur. The impact of this technique for premium IOL decentration could create significant visual disturbance. Since most patients using blood thinners do not discontinue this medication, there could be intraocular hemorrhage from inadvertent cannula contact with the iris ciliary muscle. Finally, very short eyes may not have the space to accommodate the injected volume of these antibiotic and steroid preparations.

Today’s cataract surgery is safer for the patient and shorter in duration than in decades past. Improvements in technology, techniques, and training have led to improved outcomes for our patients. Although the concept of dropless cataract surgery is clearly attractive, cataract surgeons should consider the serious issue of bacterial resistance and the unnecessary risk of the transzonular delivery of TriMoxi(+/-) Vanc. In an era of increasing cost-benefit analysis where physicians will be judged on outcomes and the allocation of limited healthcare resources, the value of dropless cataract surgery remains uncertain, risky and currently not the standard of care.

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