The cataract patient who is willing to pay for an advanced IOL or astigmatism-correcting procedure expects a premium experience from start to finish. Unfortunately, that expectation can hit a huge impediment when the conversation turns to a complex postoperative drop regimen. Telling patients that they need to administer different types of drops at different frequencies for different lengths of time does not match their expectations of a smooth experience with minimal interruption of their daily activities.

Fortunately, cataract surgeons have a growing list of alternatives to complex postop drop regimens. In this article, I’ll review the available options: combination compounded drops, steroids administered during surgery and intracameral antibiotics. First, though, let’s take a deeper look into the challenges complex drop regimens pose to your patients and practice.

CHALLENGES ABOUND

With the typical postoperative regimen of antibiotic, steroid and NSAID eyedrops, your patient may be required to manage the administration of more than 105 drops per eye. Each drop has to be used at different frequencies over different time periods. What’s more, your patient may well have a coexisting medical condition that makes instilling the drop physically difficult.

Your staff will likely spend precious time dealing with postop drops. First, they will need to handle calls from pharmacies that want to substitute a non-branded drug for a prescribed branded product because the patient’s insurance plan doesn’t cover the prescribed branded antibiotic, steroid or NSAID. Then, when the patient receives that substitution, it may have a different administration regimen, needing to be instilled at a different frequency than originally prescribed for the branded medication. Your staff will, then, need to respond to calls from confused and frustrated patients — staff time that doesn’t generate any revenue.

Thus, from the patient’s perspective as well as the surgeon and staff’s view, the postop drop regimen for cataract surgery is a far cry from the premium experience we strive to provide and the patient expects.

CONVENIENT COMBINATIONS

Prescribing combination compounded drops is one way to reduce the number and frequency of drops as well as the cost for the patient scheduled to undergo cataract surgery. Companies that provide combination compounded drops include ImprimisRx and Ocular Science. Both are 503B compounding pharmacies, meaning that they must comply with strict manufacturing practices.

These facilities provide drops in various combinations. For instance, a single bottle may contain an antibiotic, steroid and NSAID. One bottle may contain a steroid and NSAID, and a separate bottle may contain the antibiotic. This allows for tapering the anti-inflammatory regimen, as the antibiotic typically isn’t tapered. A surgeon can “mix and match” different combinations of antibiotics, steroids and NSAIDs.

Some practices purchase these bottles and sell them to the patient. Others e-prescribe the compounded drops, which are shipped to the patient’s home upon payment. Often, this cash-pay option ends up being less expensive than the three branded medications paid for by the patient’s health-insurance policy.

These combination compounded drops are not FDA approved and, thus, there are no clinical trials that have assessed their efficacy or tissue penetration. Still, they present a viable option for reducing drop burden and medication costs.

STEROIDS AT SURGERY

Another way to reduce postop drug burden in cataract surgery is to use one of two FDA-approved steroid options during the time of ocular surgery: DEXYCU (dexamethasone intraocular suspension) 9% (EyePoint Pharmaceuticals) or DEXTENZA (dexamethasone ophthalmic insert) 0.4 mg (Ocular Therapeutix).

To administer DEXYCU, the product is first shaken for at least 30 seconds for proper homogenization. It’s then drawn up and handed to the surgeon to place into the eye at the conclusion of cataract surgery (the drug can be used for any intraocular surgery). The surgeon places the spherule, which looks like a white pearl, close to the target tissue either under the iris or in the capsular bag.

The drug starts to work immediately, releasing steroid more aggressively at first and then tapering over a 30-day period, mimicking the normal steroid taper regimen. The spherule bio-erodes, and the drug is completely absorbed over the 4-week period.

DEXTENZA, the other FDA-approved steroid option, is an ophthalmic insert that is placed in the inferior punctum. It can be inserted at the start of surgery, the conclusion of surgery or even the next day in the office. To utilize the hydrogel insert, it is recommended for the surgeon to dilate the punctum with a punctal dilator, dry the area then gently glide the DEXTENZA into the interior canaliculus. The insert eludes steroids for 30 days, more intensely at the start.

With DEXYCU and DEXTENZA, surgeons nullify factors associated with topical steroid drop compliance among patients. By placing the medication in position with their own hands and witnessing it with their own eyes, surgeons can assure that the drug has been administered. Since steroids represent the most complex regimen for patients to follow due to the tapering protocol over multiple weeks after surgery, the steroid drop burden can be significantly reduced with either of these two options. An added benefit is that both DEXYCU and DEXTENZA have pass-through payment status.

Although placing a steroid into or around the eye might cause concern for an increase in IOP, clinical studies for both DEXYCU and DEXTENZA do not show such a rise, including a post hoc analysis I coauthored in January’s issue of Journal of Cataract & Refractive Surgery. Neither has demonstrated a delayed IOP elevation nor a delayed steroid response, as shown in a recent retrospective real-world study on DEXYCU that I presented as an e-poster at the 2020 AAO meeting. For added safety, DEXTENZA can be flushed out of the eye if needed.

Both DEXYCU and DEXTENZA deliver steroid effectively; DEXYCU may work slightly faster since the drug is placed into the eye close to the target tissue at the conclusion of surgery. DEXTENZA, on the other hand, gets activated when in contact with moisture from the surface tear film to begin eluding the steroid to coat the ocular surface. It then penetrates through the cornea and conjunctiva to reach the target tissue. This added benefit may help patients achieve symptomatic relief from the dry eye symptoms post surgery.

ANTIBIOTIC OPTION

Some ophthalmologists attempt to reduce the drop burden even further by placing an intracameral antibiotic such as moxifloxacin into the eye. This can be paired with the administration of either DEXYCU or DEXTENZA. (Note: Intracameral antibiotic preparations are not FDA approved.) With this combination step, patients may only need to instill the NSAID once a day postoperatively.

This combination of intracameral antibiotic injection and either DEXYCU or DEXTENZA can be used in any patient undergoing cataract surgery, as long as there is no documented history of an allergy to any of the products. This combination utilizes both an antibiotic (not FDA approved) with an FDA-approved steroid (either DEXYCU or DEXTENZA) to decrease the drop burden for patients. There are no additional contraindications for this combination.

Since it is considered standard of care to use antibiotics post-cataract surgery, adding the intracameral antibiotic solution into the anterior chamber at the conclusion of surgery will decrease the drop burden of having to use topical antibiotic drops postoperatively.

This is, of course, a striking difference from the 105-plus drops that otherwise might be needed. Other surgeons are opting to inject a combination antibiotic and steroid solution intracamerally. This compounded product is also not FDA approved and is available from ImprimisRx, Ocular Science or other similar 503B pharmacies.

MY PRACTICE

In my practice, I have used virtually every possible option to decrease the drop responsibility and increase patient compliance. In the past, I injected an antibiotic-steroid combination into the vitreous trans-zonularly — until DEXYCU and DEXTENZA became available. Thereafter, I changed my protocol to inject an intracameral compounded antibiotic from ImprimisRx or Ocular Science then selected either DEXYCU or DEXTENZA steroid at the conclusion of surgery, limiting drops to a single topical NSAID once a day.

SPECIAL CASES

For patients with astigmatism under 1 D who do not qualify for a toric IOL, I perform a limbal relaxing incision (LRI) at the time of cataract surgery if they wish less dependence on spectacles. I prescribe a topical antibiotic for all patients who undergo an LRI.

For patients who might be more prone to inflammation due to a history of uveitis, diabetic macular edema or a retinal vein occlusion, additional topical steroids may be required on top of DEXYCU or DEXTENZA. For these patients, I select DEXYCU or DEXTENZA and concomitantly place them on a topical steroid plus an NSAID.

For more complex cases, such as patients with rock-hard cataracts, tiny pupils requiring pupil-expanding devices or any other reason for prolonged surgical time, DEXYCU or DEXTENZA can be used while adding topical steroids post-surgery if warranted.

Finally, using either DEXYCU or DEXTENZA may help patients with dry eye, in that the patient’s corneal epithelium is not pummeled with a myriad of drops multiple times a day, each containing preservatives. The fewer postoperative drops to roughen the ocular surface, the better the patient’s quality of vision in the immediate postop period.

PREMIUM DELIVERY

With the latest advances in postop cataract surgery drug delivery, surgeons now have options to help patients simplify their eyedrop regimen and decrease their drop burden — assuring the premium experience they had hoped for. OM

About the Author

Cynthia Matossian, MD, FACS, is the founder and medical director of Matossian Eye Associates, an affiliate of Prism Vision Group, with multiple offices in Pennsylvania and New Jersey. She specializes in refractive cataract surgery and dry eye disease.

Disclosure: Dr. Matossian is a consultant to EyePoint Pharmaceuticals, ImprimisRx, Ocular Science and Ocular Therapeutix.