Viewpoint

To drop or not to drop?

FROM THE CHIEF MEDICAL EDITOR

Larry E. Patterson, MD

A few events occurred recently that inspired this column. The first was a personal conversation with Jim Gills as we rode together in a taxi after the Ophthalmology Management Editorial Board meeting at the AAO meeting last fall. Jim shared with me his thoughts on reducing the substantial cost to patients for postoperative antibiotic and steroid drops.

I had already tried, using trans-zonular intravitreal injections of triamcinolone and moxifloxacin at the end of cataract surgery. I first heard of this concept a few years ago from Dr. Gills and our own Paul Koch, and more recently, from Jeffery Leigner and Kevin Scripture. But I had the same issue they had — a certain number of patients, perhaps 15%, still exhibited breakthrough inflammation, and sometimes it was quite nasty. To combat that, we simply started them on steroid drops the day after surgery and found this almost completely resolved the problem. But they still were using a drop.

So Jim explained that he was now supplementing an intracameral mixture of steroids and antibiotics with 1.2 cc of Kenalog, subtenons behind the equator, far from the limbus. With this modification, he was now able to eliminate postoperative drops in most patients after cataract surgery, saving patients as much as $400 per eye.

Then came the AAO position paper that Paul Koch wrote about in our May issue. (I was going to write about it, but he beat me to it.) One of the AAO’s recommendations, with which I wholeheartedly agree, was to eliminate using prophylactic antibiotics after intravitreal injections for retinal diseases. There is no evidence they help, so the AAO added to our own medicolegal security by stating you are following the standard of care by not using antibiotics. If someone does in fact get an infection, you can’t be blamed for not using the drops.

Paul went on to write that it would be helpful if the AAO would make the same proclamation for cataract surgery in the near future. He wrote that antibiotic drops were “also not proven to prevent infections and are not approved for that indication — yet we prescribe millions of bottles each year to comply with a tradition. The cost is justified by the legal consequences of an infection in the face of not following a ‘standard of care’ that remains unproven. This is a battle best fought from the top, not from the trenches.”

This is such an important point that I want to second it. We know we reduce surgical infection risk by using betadine, isolating lashes, treating blepharitis and ensuring good wound closure. Recently, the Europeans showed the value of intracameral antibiotics.

I quit prescribing antibiotics routinely last year. I’m hoping the AAO might make a similar pronouncement on this soon. In the meantime, read Jim Gills’ article (page 56). Look at the numbers. Besides using a drop at the time of surgery, he hasn’t routinely used topical antibiotics in years. Maybe my one year of experience won’t move you, but his results are strongly worth considering.