Efficacy of Intracameral Preservative-Free Triamcinolone Acetonide in Pediatric Cataract Surgery: A Meta-Analysis

Author: Chou YY, Zhang BL, Gan LY, Ma J, Zhong Y.

Geographical coverage: Not reported

Sector: Pediatric cataract surgery

Sub-sector: Intracameral preservative-free triamcinolone acetonide

Equity focus: Not reported

Study population: Paediatric patients with cataract

Review type: Effectiveness review

Quantitative synthesis method: Meta-analysis

Qualitative synthesis method: Not applicable

Background: Paediatric cataract is one of the major causes of avoidable childhood blindness, with a prevalence of nearly 1.03 per 10,000 children. Despite advances in surgery, the postoperative inflammation remains a key challenge due to children’s stronger immune response and healing tendencies. Complications such as fibrinous uveitis, posterior synechias, and posterior capsule opacification can hinder visual recovery. Triamcinolone acetonide (TA), a corticosteroid, has been used intraoperatively to assist vitrectomy and reduce inflammation. The TA granules help visualise residual vitreous which ensure thorough removal and decrease the risk of inflammatory sequelae. While effective, conventional steroid treatments may have systemic side effects, which makes intracameral TA a potentially safer alternative. Its anti-inflammatory effect and application in paediatric cataract surgery have shown promising clinical results but require further evaluation.

Objective: To evaluate the efficacy of intracameral preservative-free triamcinolone acetonide (TA) on reducing inflammatory reactions after paediatric cataract surgery.

Main findings:

In total, five studies (308 eyes), published between 2010 and 2018, were included in this meta-analysis. Three of the included studies were randomised controlled trials, one was a prospective interventional study, and one was a retrospective case-control study.

The findings showed that intracameral TA significantly reduced postoperative inflammation compared to no TA injection. The eyes treated with TA had 65% less odds of developing cell deposits compared with untreated eyes (odds ratio, OR = 0.35, 95% confidence interval [CI]: 0.16–0.76, P = 0.008, I² = 0%). In addition TA treated eyes had lower odds of developing posterior synechias (OR = 0.44, 95% CI: 0.23–0.86, P = 0.02, I² = 0%), and and fibrinous anterior chamber reaction (OR = 0.12, 95%CI 0.01–1.05, P = 0.05, I² = 0%). Furthermore, eyes treated with TA showed significantly lower incidence of visual axis obscuration (OR = 0.10, 95% CI: 0.01–0.85, P = 0.04, I² = 0%) and posterior capsule opacification (OR = 0.09, 95% CI: 0.02–0.55, P = 0.009, I² = 0%). Notably, none of the 134 eyes that underwent intracameral TA treatment reported any severe ocular or systemic adverse events.

Methodology:  The searches were conducted in PubMed, Embase, and Cochrane Central Register of Controlled Trials up to 30^th November 2019 without any language restrictions to identify relevant studies conducted on human beings. The studies were included if they investigated the effect of intracameral TA on postoperative inflammation and intraocular pressure after paediatric cataract, and reported at least one of the following outcomes: cell deposits, posterior synechias, visual axis obscuration (VAO), posterior capsule opacification (PCO), fibrinous anterior chamber reaction and intraocular pressure (IOP). The reference lists of included studies and previously published articles were also scanned to identify additional relevant publications.

Two reviewers independently screened the articles, extracted the relevant data and critically appraised the quality of the included studies using the Cochrane Collaboration tool for randomised studies, and methodological index for non-randomised studies (minors) for non-randomised studies. Disagreements between the reviewers were resolved through discussion or by contacting a third reviewer. The findings were synthesised using a meta-analysis. Heterogeneity was assessed using the Chi-square test and I² statistics, and estimates were pooled using a fixed-effects model when heterogeneity was insignificant. However, a random-effects model was employed when I² > 50%, and sensitivity analysis and subgroup analyses were performed to explore sources of heterogeneity. Publication bias was assessed using a funnel plot and Egger’s linear regression test.

Applicability/external validity: The review acknowledged the limited evidence base on intracameral TA in paediatric cataract surgery, leading to the inclusion of both randomised clinical trials (RCTs) and non-randomised studies (prospective and retrospective) in the meta-analysis. While this approach broadened the available data, the final sample size was still very small (5 studies only). Therefore, the authors highlighted the need for more high-quality RCTs to strengthen conclusions.

Geographic focus: The review did not apply any geographical limits. However, it did not report the geographical distribution of the included studies.

Summary of quality assessment: Overall, there is medium confidence in the review’s conclusions.The searches were comprehensive. Inclusion and exclusion criteria were clearly defined, and two reviewers independently screened the articles, extracted data and assessed the study quality using established tools, with disagreements resolved through consultation with a third reviewer. Characteristics of included studies were well-documented, meta-analyses were appropriately performed, and heterogeneity was addressed. However, the review did not provide a list of excluded studies, and did not report checking reference lists or contacting authors/experts.