Transzonular approach to antibiotic delivery during cataract surgery is preferable


Concerns over the ocular surface, compliance, cost, and patient callbacks are lessened when surgeons take a transzonular approach to medication delivery during cataract surgery.


By Vanessa Caceres;Reviewed by Cynthia Matossian, MD, FACS

A transzonular/intravitreal delivery of antibiotics during cataract surgery can help surgeons better manage “the four Cs,” according to Cynthia Matossian, MD, FACS.

The four Cs are:

  • Cornea;

  • Compliance;

  • Cost;

  • Callbacks.

“For me, delivering the antibiotic/steroid combination in the anterior vitreous with a transzonular approach is the way to go,” said Dr. Matossian, Matossian Eye Associates, Doylestown, PA. “Delivering the prophylactic product at the time of cataract surgery helps eliminate many headaches.”

CounterpointIntracameral antibiotics are a win for cataract surgery prophylaxis


4 Cs outlined

First, a transzonular approach does not impact the tear film and cornea, which are often compromised in cataract surgery patients. In contrast, topical drops can exacerbate ocular surface irritation.

Second, compliance is no longer an issue when medications are delivered via a transzonular approach. “So many patients are not compliant despite the schedules we give them,” Dr. Matossian pointed out.

Patients may forget, get confused, or they are physically challenged. For example, a patient with rheumatoid arthritis or tremors may have trouble instilling drops.

Medication cost is the third issue among Dr. Matossian’s four Cs. “The cost of medications has gone up so much, and fewer and fewer insurances are covering them,” she added.

This, in turn, leads to callbacks to the office, which consume staff time and tie up phone lines. Moreover, patients prescribed topical drops for cataract surgery call the practice confused because their pharmacist has substituted a generic drug with a different dosing schedule than their original script from our practice.

With the transzonular administration of medications, compliance is no longer an issue, and the concern over cost is lower.



Pearls for transzonular approach

Dr. Matossian shares a few pearls about using a transzonular approach.

First, a transzonular approach is not difficult, although there is a manageable learning curve, Dr. Matossian said.

“You need an angled cannula to get through the zonules,” she added. “Because it’s a blind maneuver where you are pushing very gently to the bend of the cannula, you could bump the ciliary body and cause transient discomfort. You could also cause a little bleeding. Potentially, the intraocular lens could get temporarily vaulted forward from the volume change.

However, Dr. Matossian has several pearls to better manage the transzonular approach.

“I remove some of the ophthalmic viscosurgical device before I do a transzonular injection,” Dr. Matossian said. She also will warn patients that on the evening of their surgery day, they may notice floaters. “This forewarning can prevent call backs,” she pointed out.

Dr. Matossian encourages surgeons interested in the transzonular approach to call colleagues, watch videos, or visit surgeons who are using it to see if it is right for them.

Cynthia Matossian, MD, FACS


This article was adapted from a presentation that Dr. Matossian delivered at the 2017 American Society of Cataract and Refractive Surgeons. Dr. Matossian reported no financial disclosures relevant to the topic.

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