BLOG: Simplifying postoperative care can improve patient experience, outcomes
In glaucoma care, the introduction of minimally invasive glaucoma surgery has allowed us to shift our mindset from being reactive to proactive.
No longer do we wait for optic nerve damage to occur; instead, we are more aggressive with our treatments. We understand that earlier intervention ultimately improves our patients’ outcomes. Due to its IOP-lowering effect, I consider cataract surgery as a first-line interventional option for my patients with glaucoma.
When it comes to eye drops, we all know that the No. 1 hurdle we must overcome is that of adherence to prescribed therapy. The reasons for this have been well established and range from a lack of insurance coverage to forgetfulness to ocular surface discomfort. Rather than blaming patients for suboptimal compliance with medication regimens, we should consider ways to improve their experience and make treatment less of a burden.
Burden of drops
In the setting of cataract surgery, with or without a MIGS device, steroidal medications are the most commonly prescribed postoperative drops, and they are also used for the longest duration. Anything we can do to reduce the patient’s medication burden will help them to have a better experience and ensure improved results.
Consider the typical patient with glaucoma who, after cataract surgery, will be prescribed antibiotic, nonsteroidal anti-inflammatory and steroid drops on top of their existing glaucoma regimen, which may include two or even three antihypertensive medications. This could add up to 12 to 14 eye drops a day. Adding drops on top of drops, with a dosing schedule that changes over time, is incredibly confusing for our patients. In fact, sometimes patients mistakenly stop taking their glaucoma drops after cataract surgery.
For all of these reasons, I have increasingly found Dextenza (dexamethasone ophthalmic insert 0.4 mg, Ocular Therapeutix) to be useful in patients with glaucoma who are undergoing cataract surgery with MIGS. The preservative-free intracanalicular insert provides a consistent level of steroid to the ocular surface over 30 days, thereby eliminating the most complex, tapered drop regimen and thereby improving patient compliance. On top of that, the need for fewer drops benefits ocular surface health. This occurs by reducing corneal exposure to the preservatives found in the topical agent. An indirect additional benefit of Dextenza is the occlusion of the tear duct, which allows topical medication that is being administered to remain on the ocular surface longer. This results in better absorption. These two benefits are exceedingly important to refractive cataract outcomes. In short, minimizing drops takes some of the compliance concerns out of patients’ hands and helps to make their overall experience a better one.
We always monitor patients for postoperative IOP spikes regardless of the medication scenario, as we know that there is a possibility that a small number of patients could have a steroid response. More commonly, however, we observe uncontrolled inflammation in patients who are taking their drops consistently. I have more concern over the consequence of secondary inflammation, which increases IOP, as opposed to encountering a patient who is an undiagnosed steroid responder. If ever necessary, the intracanalicular insert can easily be removed or washed out.
- We know compliance is a problem: Dextenza helps us help patients by taking a postoperative drop out of the equation.
- With consistent steroidal coverage, inflammation is better controlled, therefore reducing the likelihood of a spike in swelling.
- Preservative-free delivery benefits ocular surface health.
Glaucoma care is a journey from point A to point B. Our job is to take patients along that entire journey while maintaining their best functional vision. Our goal should be to help guide them through the natural obstacles that will occur on this journey. When we arrive at an obstacle, we need to consider which of our options has the best risk-to-benefit ratio for that individual patient. Cataract surgery with MIGS and Dextenza checks all the boxes.
Prescribing patients a drop on top of drops is a passive approach to managing their postoperative care. Now, we have a proactive interventional option that eliminates a drop from patients’ treatment burden. Dextenza represents another shift in our changing paradigm.