management
Refining Patient and Dosage Management
Teaching elderly patients to dose correctly
can increase overall satisfaction in cataract surgery.
BY WILLIAM C. ASHFORD, M.D.
This article will describe the dosing regimen for eye drops that we have found to be optimal, as well as outline a dosing management program for patients to help them adhere to their regimen.
A Need for Patient Education
I have been in private practice since 1980 in Jackson, Miss., and have also been the surgeon for the Ursic/Ashford Eye Institute in Tuscaloosa, Ala., since 1991. I opened my own surgery center in Jackson in 2003 and in Tuscaloosa in 2005. About 2,000 cataract cases are performed at these two centers per year.
After cataract surgery, we noticed that a few of our patients would return 1 week postop presenting with iritis. After the exam, we would specifically inspect the patient's postop kit and check the bottles. We often found that the medications contained in the kit were completely full with unbroken seals, which not only explained the iritis, but also confirmed that the patient had not used any drops postop. Upon confrontation, the patient would admit that they had not used their drops, often because they did not know how to administer them.
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The Value of Preservatives in Antibiotic Solutions |
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Are
preservatives in antibiotics unnecessary or do they add an extra protective edge
to a solution? It has been argued that the very nature of the fourth-generation
fluoroquinolones as effective killing solutions negates any risk of contamination and infection. However, because antibiotic eye drop bottles are often carried around by patients for days after surgery, the bottles themselves could be at risk for contamination and the addition of a preservative may offer additional protection for the patient, according to Y. Ralph Chu, M.D., medical director of the Chu Vision Institute, P.C., in Edina, Minn. CONTROLLED-SETTING STUDY Dr. Chu performed a study comparing the effects
of contamination with Candida albicans on bottles of gatifloxacin 0.3% with
benzalkonium chloride (BAK) (Zymar, Allergan) vs. moxifloxacin 0.5% self-preserved
(Vigamox, Alcon Laboratories, Inc.) and found that the likelihood of infection stemming
from bottle contamination was higher for the Dr. Chu says that he performed the study to answer questions that had been raised by other researchers. "There were some equivocal studies showing contamination on tips of these bottles that patients carry around with them," he says. "Our question was, can organisms on or in the bottle inoculate a cornea?" In the study, 12 New Zealand White rabbits were randomly assigned doses of either gatifloxacin 0.3% with BAK or moxifloxacin 0.5% self-preserved, both of which were contaminated with C albicans after a LASIK-type procedure where a corneal flap was created. The eyes were checked for 5 days after surgery, twice a day, for signs of infection. Signs included inflammation, redness, flap slippage and manually-induced irritation. At the end of the study, 67% of the moxifloxacin group tested positive for C albicans on corneal cultures and 50% had actually exhibited signs of ocular infection. From the gatifloxacin group, 0% tested positive for C albicans or showed signs of ocular infection. Dr. Chu says that while the likelihood of infection from contaminants on the tip or threads of a bottle of antibiotic may be low, it is important to provide the best possible protection for patients in the postoperative period. REPORTS FROM CLINICAL PRACTICE More data are required to determine whether additional preservative is required to protect patients from contamination on or in multi-use bottles of antibiotic in the postop period. It is possible, however, that the most useful information will come from real-world experience. To that end, Robert Mack, M.D., founder of Midwest Refractive Surgery and Cornea Consulting, P.C., in Hoffman Estates, Ill., collected data on several patients who had positive fungal cultures that he suspected originated from multi-use bottles of unpreserved moxifloxacin. Dr. Mack presented one of the five cases that he found in his practice during ASCRS. The case he presented was one in which a patient presented with multi-species fungal keratitis.2 After the patient was unsuccessfully treated with topical antifungal agents, a therapeutic penetrating keratoplasty was performed and cultures were taken from the cornea. The bottle tip and contents were also cultured in a sterile setting and analysis was performed on both the cornea and bottle cultures using staining. The cultures from the bottle of moxifloxacin 0.5% showed the presence of multi-fungal keratitis contamination, similar to that found in the corneal cultures. Dr. Mack also found that 13 of 33 (39%) consecutive bottles of moxifloxacin 0.5% retrieved from patients referred for keratitis grew some species of fungus, as opposed to 3% to 5% of other in-use ophthalmic medications showing fungal contamination in a previous study by Schein et al.3 The Schein study cultured bottle caps, drops and contents of 220 in-use ocular medications from 101 patients with nonmicrobial ocular surface disease. "All of the medications in the Schein study were multiple-use containers, so of course all had preservatives in them, since, until Vigamox, all multiple use ophthalmic preparations contained a dedicated preservative," says Dr. Mack. "Interestingly, Vigamox does contain an unspecified amount of boric acid, for reasons that I haven't been able to determine. Sometimes it [boric acid] is used to adjust tonicity." In his presentation, Dr. Mack concluded that corneal and bottle cultures should be considered to check for the presence of fungal contamination when patients who have been treated with moxifloxacin show signs of keratitis. "Dr. Mack's study is pretty convincing that having a preservative or having anti-fungal protection in your antibiotic solution can be protective to the patient," says Dr. Chu. |
A Successful Dosing Regimen
Success with any regimen requires drugs that are reliable and time-tested, and that have few side effects. For these reasons we prefer to use a steroid, a fourth-generation fluoroquinolone and an NSAID during the preop and postop periods.
We use a combination of predisolone acetate, (Pred Forte, Allergan), gatifloxacin (Zymar, Allergan) and ketorolac tromethamine 0.4%, (Acular LS, Allergan). Since beginning the use of gatifloxacin and ketorolac 0.4% preoperatively, we have noticed that eyes are noticeably quiet in the postop period. The rapid kill of bacteria with gatifloxacin, as formulated in Zymar, and the significant decrease in postop cystoid macular edema, especially for diabetics, with the use of ketorolac 0.4% add a significant benefit for our patients.
Dosage Management Program
We primarily serve an elderly population, so educating the patient along with their attending family is extremely important. With the excitement of impending surgery during the preop evaluation, and with IV sedation on the day of surgery, it is imperative to have both the patient and caregiver involved with instructions on use as well as the purpose of the medications. For this reason, I have designed and implemented a dosage management program as part of my standard preop routine. It seems that the optimal time for providing this instruction is during the preop visit.
Not surprisingly, our more educated patients today are much less likely to ignore their preop and postop treatments. Our dosage management program consists of two vital areas:
■ Administration. Patients and caregivers often do not know how to properly instill drops into the eye. My nurse is often asked, "Will more than one drop be more effective than just one drop?" and "Do I have to hit the eye with the drop for it to be effective?" A little extra time spent with the patient at this point helps to ensure proper administration and compliance. I feel it is important to actually put the drops into the patient's eye and have the patient and caregiver properly demonstrate their ability to successfully instill the drops, using artificial tears for practice. This is a significant step in ensuring compliance with our preop and postop regimen. We are often surprised that even some patients who are doctors and nurses by profession do not know to press on the "punt" on the bottom of the bottle to properly instill their drops.
■ Branding. Coupled with educating the patient and caregiver on how to administer the drugs, our dosage management program also addresses why they are using the drugs. To accomplish this, we "brand" the drops that they are given to take home. By associating the name of the drop with the purpose of the drop, we have found that more patients are apt to contact our staff if they have any questions about the preop and postop routine. We tell them, "Pred Forte is used to suppress the inflammation caused by surgery. Zymar is used to decrease the population of germs around the eye until the wound completely heals and Acular LS is used to prevent swelling of the macula after surgery to insure better vision in the immediate postop period." We ask the patient and caregiver to vocally recite this back to us before they finish preop instruction, as it is important for patients to know the names of their drugs.
In addition to our preop program, we always take time postoperatively to reiterate instructions and, of course, answer any questions and address any concerns from the caregiver at discharge time.
Education Equals Patient Satisfaction
NSAIDs and anti-infectives are an integral part of cataract surgery, as they directly affect the success of the procedure. The little bit of extra time my staff and I spend with the patient both pre and postop, has proven to be extremely effective. As the patient understands the purpose of the drops we are prescribing, they become more compliant. Overall, this educational program that I have recently implemented addresses two overarching issues: doctor/patient communication as well as pre- and post-operative dosage management — two aspects of all ocular surgeries that, while sometimes ignored by patients and physicians alike, ultimately determine the success of the procedures and overall patient satisfaction.
William C. Ashford, M.D., is the founder of the Ashford Eye Clinic in Jackson, Miss., and is surgical director of the Ursic/Ashford Eye Institute in Tuscaloosa, Ala. He can be contacted at (601) 985-9120.
REFERENCES
1. Chu YR. Effects of contamination of bottle of Zymar and Vigamox with Candida albicans on incidence of post-LASIK corneal flap infection. Presented at: The American Society of Cataract and Refractive Surgery Annual Meeting; March 17-22, 2006; San Francisco, Calif.
2. Mack R. A case of recalcitrant Fusarium solani keratitis leading to therapeutic penetrating keratoplasty in a patient with fusarium solani contamination of a bottle of moxifloxacin 0.5% ophthalmic solution. Presented at: The American Society of Cataract and Refractive Surgery Annual Meeting; March 17-22, 2006; San Francisco, Calif.
3. Schein OD, Hibberd PL, Stark T, Baker AS, Kenyon KR. Microbial contamination of in-use ocular medications. Arch Ophthalmol. 1992;110:82-85.
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