Intracameral dexamethasone injection in the treatment of cataract surgery induced inflammation: design, development, and place in therapy

Abstract

Cataract surgery is one of the most commonly performed surgeries worldwide, with nearly 20 million cases annually. Appropriate prophylaxis after cataract surgery can contribute to a safe and quick visual recovery with high patient satisfaction. Despite being the current standard of care, the use of multiple postoperative eye drops can create a significant burden on these patients, contributing to documented and significant non-adherence to the postoperative regimen. Over the past 25 years, there have been a few studies analyzing the use of intracameral dexamethasone (DXM) in controlling inflammation following cataract surgery. This review explores various drug delivery approaches for managing intraocular inflammation after cataract surgery, documenting the strengths and weaknesses of these options and examining the role of intracameral DXM (among these other strategies) in controlling postoperative intraocular inflammation. Intracameral DXM has a particular advantage over topical steroids in possibly decreasing postoperative inflammatory symptoms and objective anterior cell and flare scores. Compared to topical steroids, there may be a slightly less theoretical risk of significant intraocular pressure spikes and systemic absorption. In addition, surveys indicate patients prefer an intraoperative intracameral injection over a self-administered postoperative eye drop regimen. However, there are several adverse effects associated with intracameral DXM delivery that are not seen with the noninvasive topical approach. Although it is unlikely that intracameral DXM will replace topical medications as the standard management for postoperative inflammation, it is seemingly another safe and effective strategy for controlling postoperative inflammation after routine cataract surgery.

Keywords: Dexycu®; Surodex®; cataract surgery; inflammation; intracameral dexamethasone; intraocular pressure cataract surgery; intraocular steroids; topical steroids.

Figure 1

A model of the mechanism of action upon administration of intraocular DXM. Notes: The steroid traverses the cellular membrane as a free molecule and interacts with glucocorticoid-receptor. The dimerized complex enters the nucleus where it acts as a transcription factor to upregulate and downregulate certain products to promote its anti-inflammatory effects. Additionally, free DXM inhibits the production of prostaglandins, which are implicated in post-surgical ocular symptoms. Abbreviations: DXM, dexamethasone; CBG, cortisol-binding globulin; GR, glucocorticoid receptor; HSP, heat-shock protein; IL-1RA, interleukin-1 receptor antagonist; IL-10, interleukin 10; IL-1, interleukin-1; IL-1b, interleukin-1b; Cxcl-10, chemokine (C-X-C motif) ligand; TNF-α, tumor necrosis factor α; COX-1, cyclooxygenase 1; COX-2, cycloxygenase 2.