In 2017, an unexpected cluster of patients in the Dallas area who had recently undergone dropless cataract surgery (DLCS) developed toxic posterior segment syndrome (TPSS), a rare, non-infectious inflammatory condition affecting the back (posterior segment) of the eye after intraocular surgery. It was later determined that a compounded formulation of intraocular triamcinolone-moxifloxacin (Tri-Moxi) used during the procedures caused the TPSS and contained high concentrations of poloxamer 407, a solubilizing and stabilizing agent.
In a new retrospective case series published in Ophthalmic Surgery, Lasers & Imaging Retina, Texas Retina’s Rajiv Anand, MD; Deborah Y. Chong, MD; Lori E. Coors, MD; Gary E. Fish, MD; Timothy S. Fuller, MD; Robert C. Wang, MD; and Ashkan M. Abbey, MD, worked with colleagues from Stanford University, Wills Eye Hospital, and University of Texas Southwestern Medical Center to detail the clinical findings, long-term outcomes, and prognostic factors in 50 eyes affected by TPSS after DLCS.
About Dropless Cataract Surgery
Over the past decade, DLCS has gained popularity. In this approach, the cataract surgeon delivers steroid and antibiotic during surgery to help prevent infection rather than through a regimen of postoperative drops, with the goal of reducing medication costs, simplifying postoperative care and improving patient compliance.
Despite its growing adoption, DLCS remains controversial due to the lack of standardized injection agents or techniques endorsed by the American Academy of Ophthalmology. There is also no U.S. Food and Drug Administration (FDA)–approved intraocular injection to prevent eye infections, so compounding pharmacies often provide non-FDA-approved formulations of Tri-Moxi for use during DLCS.
Study Findings and Clinical Implications
The research team’s work represents the largest case series of TPSS to date and offers insights on retinal toxicity, medication compounding and patient safety in modern cataract surgery.
Key findings that emerged from their analysis include:
- Nearly half of affected eyes (22/50) developed severe disease, with substantial and often irreversible visual impairment.
- Optical coherence tomography (OCT) and fluorescein angiography revealed characteristic patterns of outer retinal damage, optic disc leakage and foveal avascular zone enlargement associated with disease severity.
- Presenting visual acuity and angiographic findings provided important prognostic information regarding long-term visual outcomes.
- The investigation identified unusually high concentrations of poloxamer 407 in the compounded formulation, highlighting the potential toxicity of inactive ingredients and their degradation products.
“Although this outbreak occurred nearly a decade ago, its lessons remain highly relevant today,” shares Dr. Abbey, who serves as Texas Retina’s Director of Clinical Research for Dallas. “As dropless cataract surgery continues to evolve, this experience reinforces the importance of medication safety, rigorous compounding standards and the need for standardized, FDA-approved intraocular formulations.”
The researchers hope these findings help increase awareness, improve early recognition of retinal toxicity and prevent similar events in the future.