By watching my three children playing together, I’ve learned that the importance of pain depends on whether you’re the one giving it or the one receiving it. Similarly, the size of the burden of using eye drops depends on whether you’re the one prescribing them or taking them. We physicians have grown accustomed to prescribing three eye drop medications to be taken for a month or longer after surgery, assuming that the average cataract patient — age 69 — will take them flawlessly. How wrong we are! Studies by Angela An and others have shown that more than 90% of patients taking eye drops fail. If we listen, our own patients tell us about their problems with compliance; in a 2018 study by MDbackline asking patients what was their biggest complaint about cataract surgery, 10% brought up the subject of eye drops as a consistently formidable task.
Fortunately, we now have some effective and on-label alternatives. Two sustained delivery dexamethasone preparations, Dexycu (EyePoint) and Dextenza (Ocular Therapeutix), can provide adequate steroid after surgery to eliminate steroid eye drops. These are simple to adopt, invisible to the patient and actually enhance the postop outcome because there is no toxicity to the ocular surface. Both products are covered by pass-through reimbursement, making calls back from the pharmacy a thing of the past. We have already successfully adopted these medications in our practice and have all but given up prescribing topical steroids to cataract patients.
For prevention of endophthalmitis, multiple studies in the U.S. and abroad have demonstrated the superiority of intracameral antibiotics over topical therapy at preventing postoperative endophthalmitis. Although no FDA-approved intracameral antibiotic exists in the U.S., an upcoming study organized by the American Society of Cataract and Refractive Surgery hopes to gain approval of an inexpensive moxifloxacin product. In any case, even approved topical antibiotics are not specifically indicated for preventing endophthalmitis; whatever antibiotic you use after cataract surgery, it is an off-label use. Our practice is joining about half of our high-volume U.S. colleagues who use intracameral antibiotics as a safer alternative to drops.
What about the nonsteroidal? About 90% of U.S. cataract surgeons prescribe NSAIDs. Most do this because several large studies have shown that topical NSAIDs prevent cystoid macular edema, even in patients without risk factors for a “leaky macula” (diabetes, an epiretinal membrane or other macular pathology). But these studies supporting NSAIDs all involved steroids that were delivered topically. Because we know that patients don’t take their drops consistently, is the “need” for a nonsteroidal in these studies really caused by a lack of compliance with the steroid? Compliance problems disappear with sustained delivery steroids, so a NSAID may not be necessary at all. If you do believe a NSAID is necessary with sustained delivery steroid, there is an intracameral NSAID currently available. It is ketorolac 0.3% combined with phenylephrine 1% in the form of Omidria (Omeros). Infused through the anterior chamber with balanced salt solution during surgery, it maintains pupil dilation while also saturating the intraocular receptors for cyclooxygenase 1 and 2 for at least 10 hours after surgery, according to canine studies performed in the process of FDA registration. It’s likely that the drug effect lasts for at least several days. In routine cases, this level of nonsteroidal will likely control inflammation and prevent CME adequately.
Eric Donnenfeld and I are undertaking two studies to determine how well these sustained-release drugs control inflammation in routine cataract patients, comparing them to traditional drop therapy in contralateral eyes. As far as inflammation control, we hope to see similar results in both eyes. As far as patient preference, we know very well how patients will vote. Like my children causing pain to each other, patients will always vote for the less painful path that involves fewer eye drops.
Disclosure: Hovanesian reports he is the founder of MDbackline and is a consultant to a number of pharmaceutical companies, including Alcon, Allergan, Bausch + Lomb, EyePoint, Novartis, Ocular Therapeutix, Omeros and Sun Pharma.