SURGICAL PEARLS

IV-free Cataract Surgery

BY JOHN BERDAHL, MD & CHRIS BENDER, CRNA

Cataract surgery is one of the most refined and successful surgeries in all of medicine. Yet, despite extraordinary innovations, one of the biggest pain points continues to be the IV, which can cause a great deal of anxiety for patients. Also, the process involved in utilizing an IV slows down staff and impedes patient flow.

Replacing traditional intravenous sedation with sublingual sedation removes the necessity of an IV and saves a great deal of time. This, in turn, allows doctors more time to review the procedure and expectations with patients, and allows for better, more standardized, and more comfortable sedation. However, sublingual liquid sedatives are bitter-tasting and difficult to hold under the tongue for several minutes. But there is a new alternative — IV-free surgery via the MKO Melt (Imprimis Pharmaceuticals).

MKO Melt

The MKO Melt is a patent-pending, compounded, conscious sedation formulation in troche form that is an alternative to IV anesthetic. These “meltaways” contain 3 mg midazolam, 25 mg ketamine, and 2 mg ondansetron, and are administered sublingually to sedate patients undergoing ocular surgical procedures. The effects are evident after 2 to 3 minutes and peak at about 15 minutes.

“Many centers have multiple anesthetists or anesthesiologists who rotate through, and each person operates a little differently. There’s no standardization,” says John Berdahl, MD, of Vance Thompson Vision in Sioux Falls, S.D. The meltaways provide more consistent dosing.” The MKO Melts come in a package of two, which he says is sufficient for about 95% of patients. “Although some may need a supplemental IV — based on age, size, and anxiety level — for the most part, the majority of patients will be adequately sedated with one or two meltaways.”

Dr. Berdahl mentions another benefit: “The transition in and out of sedation is much less jarring because patients don’t wake up and startle, and then fall asleep.”

The MKO Melt also allows for more consistency in timing and delivery. Cataract surgery only requires light sedation, but in many cases, the need for an IV ramps up the patient’s anxiety. This could cause a patient to require more sedation and could affect the timing of the procedure. The sublingual melts provide a way to prevent anxiety because the sedation begins to take effect while patients are still calm, thus helping them to remain calm. “We started seeing this effect with the medications in liquid form,” says Chris Bender, CRNA, nurse anesthetist and owner of Sleepy Eye Anesthesia Services in Sioux Falls, S.D. “Patients were relieved they didn’t need an IV, and their anxiety level was significantly reduced. The meltaways give us the same ability to stay ahead of anxiety and give the patient a smoother experience without needles and without the discomfort of having a bitter liquid in their mouths.”

And then there is the obvious appeal to patients. “There are patients who choose not to have cataract surgery due to a phobia of needles who may now choose to go ahead with surgery,” Dr. Berdahl says. “In fact, we’ve had people seek us out because they heard we can perform IV-free cataract surgery.”

Along with contributing to an even better experience for cataract surgery patients, meltaways can be used as a pre-op sedation before the IV is even started. Relaxing a patient beforehand makes each subsequent step that much less traumatic and allows personnel to keep patient anxiety in check before it becomes unmanageable.

A Safe, Cost-effective Option

According to Dr. Berdahl, his IV costs average around $17 to $18 per patient, not including staff time or patient flow. The MKO Melts are $25 for a package of two; however, if you consider the costs of the IV, the drug, and the staff time to administer and monitor it, the meltaways have proved to be a better use of financial resources. Additionally, as patient flow improves, the number of procedures performed each day can increase.

Eliminating the IV may reduce overall costs but does not do so at the expense of safety. As cataract surgery is one of the safest procedures in medicine, the chances of a patient who has been sedated sublingually having an adverse effect and needing immediate IV access is slight.

Cataract surgery is a relatively benign process. Typically, if a patient is going to experience an adverse event, it would likely be an allergic reaction to the antibiotic drops, local anesthetic, or sedation medications. These would present fairly quickly, often in the pre-op area. If an adverse event should occur, medical professionals on hand can quickly administer an IV during the surgery.

“However,” Dr. Berdahl states, “to date, we have done thousands of cases and have needed to start an IV in less than 1% of our patients.” If there is still concern, it is certainly possible to start an IV and hep-lock it as a comfort measure. Then, as the procedure with the MKO Melt becomes more familiar, this should no longer be necessary.

Bender notes that in the unlikely event of an allergic reaction, the use of an EpiPen can buy some time to establish IV access and take resuscitative measures. “This is also something that can be assessed on a patient-to-patient basis,” says Bender. “During the pre-op assessment, if the patient is very sick or has multiple medical problems, we can start an IV or hep-lock just in case.” However, most patients who present for cataract surgery will not need an IV and, given the choice, prefer not to have one.

A MAC Procedure

Eliminating the need for an IV also does not eliminate the need for anesthetists and anesthesiologists, who remain a crucial component of cataract surgery. It is still a monitoried anesthesia care (MAC) procedure and can be billed as such, even without the IV. “Personally, I feel much more comfortable having anesthesia personnel present when performing intraocular surgery, because of potential challenges and unpredictable events that would require their help and knowledge,” says Dr. Berdahl.

Bender agrees that anesthesia personnel should always be present. Ketamine is an anesthetic, and, although it is typically an IV anesthetic, anesthesia personnel should still be present to administer the sedation, even in troche form. They specialize in sedation and know what to expect with ketamine. Regulatory requirements also come into play.

“It is a similar regulatory situation to propofol,” Bender explains. “Although nurses can use it in specific situations with specific order sets, they are not allowed to administer propofol sedations for procedures. Ketamine is classified the same — it is an anesthetic and anesthesia personnel should be delivering it.”

The Future of Novel Delivery

“I think there will be huge possibilities for other settings and procedures,” Bender says. “As far as other applications for this product, the sky is really the limit.” ■