After cataract surgery, patients must place topical antibiotic and steroid drops into their eyes for up to 1 month postoperatively. A method to eliminate these drops is long overdue. Thus, the arrival of Tri-Moxi (triamcinolone acetonide and moxifloxacin HCl) by Imprimis marks the beginning of the next revolution in cataract surgery. Administered transzonularly or through the pars plana after IOL placement and before viscoelastic removal, Tri-Moxi is marketed as the long-awaited answer to ophthalmologists’ and patients’ desire for so-called dropless cataract surgery.
Tri-Moxi comes with the obvious convenience of eliminating postop drops. One study suggested that 93% of patients improperly administer eye drops, either by missing the eye, instilling the incorrect number of drops, contaminating the bottle, or skipping doses. However, with Tri-Moxi, noncompliance becomes a nonissue.1 Moreover, the potential exists to significantly lower overall costs to the health care system. A postop drop regimen might include moxifloxacin HCl 0.5% (Vigamox; Alcon), prednisolone acetate 1% (Pred Forte; Allergan), and ketorolac 0.5% (Acular; Allergan), which can cost $165, $31, and $9, respectively.2 A regimen consisting only of brand-name drugs could cost as much as $600. Conversely, a single dose of Tri-Moxi costs just $25 to $35. The medication is more affordable and more convenient than the standard of care—a win-win combination that commands careful attention and evaluation from cataract surgeons nationally.
There are disadvantages to any medication, and Tri-Moxi is no exception. In routine cataract surgery, vision can be as good as 20/20 on postop day 1. Tri-Moxi, on the other hand, is milky and gets into the visual axis, and acuity is transiently decreased to between 20/30 and 20/50. With proper preop education, unease on the part of the patient can probably be avoided here, but the “wow” factor that patients and cataract surgeons crave is ultimately blunted.
Acquiring the medicine is also not necessarily straightforward. Unlike Leiter’s Pharmacy, not all Imprimis pharmacies are registered as FDA 503B outsourcing facilities. As a result, the drug might not be obtainable for university-based surgeons, where regulations are more stringent. In addition, the cost of the injectable drug cannot be passed directly to the patient; the ambulatory surgery center or hospital must legally bear that additional cost.
Tri-Moxi is not for everyone. Because of the potential for a steroid response from the triamcinolone, known steroid responders, ocular hypertensives, or patients with glaucoma should probably be spared this offering. Postoperative topical NSAIDs are a mainstay for patients at high risk of developing cystoid macular edema (ie, diabetics); one might argue that if this drop must be given, the benefit opportunity is lost, and so why not just give all three medicines topically (Vigamox, prednisolone acetate, and ketorolac)?
Overall, Tri-Moxi offers a cheap, effective, and guaranteed method of delivery for postop medications to most patients. As cataract surgeons, we must carefully weigh the benefits that this formulation promises against the pitfalls outlined above. Time will tell whether Tri-Moxi is the revolution we have been waiting for or the precursor to a prepackaged, commercially available formulation yet to come.
1. An JA, Kasner O, Samek DA, Levesque V. Evaluation of eyedrop administration by inexperienced patients after cataract surgery. J Cataract Refract Surg. 2014; 40(11):1857-1861.
2. GoodRx website. https://www.goodrx.com. Accessed August 19, 2016.