Advances in Pre- and Postoperative Cornea Care

Medical management complements other advances in cataract surgery and helps us fulfill patients' heightened expectations.

By Elizabeth A. Davis, MD, FACS

Every decision we make for our cataract patients before, during and after surgery is based on years of published research and our own careful consideration. We continually refine and improve both the outcomes and the patient experience of cataract surgery. We aim to achieve the best possible surgical outcomes in terms of visual acuity, comfort, recovery time and reduced risk of complications.

Changes in instruments, devices, techniques and drugs are pieces of the whole picture. For example, phacoemulsification permitted smaller incisions, which led to the development of foldable IOLs, which have been further enhanced in the form of premium IOLs.

Today, femtosecond lasers seem poised to revolutionize cataract surgery, once again raising expectations for visual outcomes. Advances in pre- and postoperative medical management complement other bar-raising advances in cataract surgery, as well as our patients' ever-higher expectations.

Focus on the Ocular Surface

In recent years, the approach to preoperative cornea care has changed. We're paying much more attention to the ocular surface, recognizing that ensuring a quiet, healthy ocular surface before cataract surgery is a critical component of our surgical outcomes.

It's not just a matter of enhancing comfort and healing, although those things certainly are important—it affects our visual outcomes. When we treat blepharitis and optimize the tear film preoperatively, we obtain a more accurate set of measurements upon which to base surgical planning. If problems with the ocular surface impact the measurements taken with keratometry, corneal topography, refraction, and wavefront aberrometry, then the surgery cannot fulfill the high level of precision and predictability promised by advances such as femtosecond lasers and premium IOLs.

The moral of the story: Treat any corneal surface problems with the corneal surface before you take measurements. I use a non-steroidal anti-inflammatory drug (NSAID) for inflammatory dry eye and azithromycin, (Azasite, Ista Pharmaceuticals) along with lid scrubs, for blepharitis.

Medication Before and After Surgery

Top surgical devices and IOLs set a high bar for outcomes—one that medical measures must support. But regardless of whether you have the financial and practical means to employ the latest devices in performing cataract surgery, you can use the latest medical management.

Once any ocular surface problems are under control, I follow a standard practice of starting patients on azithromycin for 1 week before surgery to control any blepharitis or meibomian gland dysfunction, clear the lid flora, sterilize the lids, and prevent endophthalmitis. I start patients on an NSAID, usually bromfenac (Bromday, Ista Pharmaceuticals), at the same time to get a head start on controlling pain and inflammation.

Postoperatively, I use moxifloxacin (Vigamox, Alcon), a broad-spectrum 4th generation fluoroquinolone, while having the patient continue bromfenac with the addition of prednisolone (Pred Forte, Allergan) for 3 to 4 weeks.

An NSAID is most commonly used in combination with a steroid after cataract surgery. It could be used alone if you're not expecting a lot of anterior chamber inflammation, but only the steroid will really knock down any breakthrough inflammatory effect. However, with the advent of femtosecond laser-assisted cataract surgery, a steroid-free postoperative approach may be possible in the future.

By using the laser to emulsify the lens, we may exert less energy on the eye than we do with phacoemulsification, which in turn may reduce postoperative inflammation. If this proves reliably true, then we could limit steroid use to high-risk cases and use an NSAID monotherapy. We need to see more studies and get more hands-on experience with femtosecond lasers before we make such a change, but it is a reasonable possibility for the future.

Of course, NSAIDs are contraindicated for patients who have any persistent, non-healing epithelial defect, as well as for those whose severe dry eye puts them at risk for a corneal melt (although severe dry eye must be brought under control preoperatively in all patients).

Choice of NSAID

I used bromfenac when it was labeled for twice a day use, and I liked the convenience and comfort compared to ketorolac, which patients reported caused lots of stinging and burning. The difference in comfort improved patient compliance, and bromfenac's change to once-a-day dosing enhanced compliance even further. Bear in mind that every drop we prescribe requires a 3- to 5-minute wait between drops, so the more drops we prescribe, the wearier patients become when administering them over a period of weeks.

The one-a-day dose also means that there's less drug and less preservative on the eye, which is always a good thing. Patients in this population are often using a lot of drugs in addition to the drops prescribed for cataract surgery. They may also have memory issues that impact their compliance, arthritis that makes a squeeze bottle hard to use, or a caretaker who stops by once a day, so once-daily dosing is more beneficial and possibly crucial to these patients than it would to an otherwise fit 30-year-old.

Of course, efficacy is the most important factor, and bromfenac's efficacy is excellent. Patients I've seen have better comfort, decreased inflammation, and reduced incidence of cystoid macular edema. In clinical trials, patients using bromfenac showed a clinically significant inflammation reduction as early as postoperative day 8, and 51% had no inflammation by day 15.¹ The day after surgery, 84% of bromfenac users said they were pain free.

Meeting High Expectations

What are your patients' expectations for cataract surgery? Many of my patients come through the door expecting that cataract surgery will mean reduced dependence on eyeglasses, precise refractive outcomes with better Snellen acuity and quality measures like contrast sensitivity and a comfortable, pain-free recovery without dry eye. To meet those high expectations, patients need good pre-, intra- and postoperative care and management, as well as realistic expectations and clear communication.

Patients are more compliant if they understand why they're taking medications. For example, patients don't mind taking the extra time up front to treat ocular surface problems when my coordinators explain how the health of the ocular surface affects surgical outcomes. They receive a printed sheet that lists their medications, why I've prescribed them, and how substituting a generic drug or another drug in the same class risks uncertain outcomes. Getting the prescribed drugs and complying with instructions will promote healing, comfort, and clear vision, and patients who understand that are more likely to be compliant.

Only the right medical management before, during, and after cataract surgery can enable us to reach the heights promised by new surgical technologies. Optimizing the condition of the ocular surface before surgery yields more accurate measurements that support more precise surgery and better vision. Effective medications control pain and inflammation to realize patients' expectations for comfort. Convenient dosing supports compliance, which in turn results in better outcomes. And coordinated medical management throughout the period of weeks before and after surgery supports the kind of positive surgical experience that's so important in our practices.

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Elizabeth A. Davis, MD, FACS, is an adjunct clinical assistant professor at the University of Minnesota in Minneapolis and director of the Minnesota Eye Laser and Surgery Center, Minnesota Eye Consultants, Bloomington.

REFERENCE

1. Chandler SP. Integrated phase 3 clinical trials of bromfenac sodium ophthalmic solution dosed once daily for ocular surgery. Poster presented at: 114th Annual Meeting of the American Academy of Ophthalmology; October 16-19, 2010; Chicago, IL. Abstract P0281.