Eyeworld

EW FEATURE 66 by Rich Daly EyeWorld Contributing Writer The opportunities and obstacles clinicians see in the emerging anesthesia option C linicians experienced with the newer anesthe- sia option of MKO Melt (Imprimis Pharmaceuti- cals, San Diego) say it has important advantages and some limitations. MKO Melt is a form of sublin- gual sedation for cataract and other surgery named for its medications— midazolam (3 mg), ketamine HCl (25 mg), and ondansetron (2 mg). Patients place it under their tongue prior to surgery and feel the effects within a couple of minutes. Full effect takes place around 10 min- utes and lasts about 45 minutes to an hour, said Michael Greenwood, MD, Vance Thompson Vision, Far- go, North Dakota. "It has a nice synergy with the ketamine and the midazolam to provide analgesia," said John Berdahl, MD, associate pro- fessor of ophthalmology, University of South Dakota. "Specific to cataract surgery, patients For Dr. Greenwood, who uses the melt for almost all of his intra- ocular surgeries, including cataracts, MIGS, DMEK, and refractive lens exchanges, the primary advantage is not needing to place an IV. "That saves the patient time from having to get a needle stick and also time from having to have it removed," said Dr. Greenwood, who opted for the melt in his own phakic IOL surgery and has used it in procedures on close relatives. The patient flow benefits in- clude allowing the staff to do other work and help the patient have an overall better experience, which reduces the chance for a delay due to waiting for an IV to be placed, Dr. Greenwood said. The MKO Melt is titratable, which allows giving one, one and a half, or two to patients depending on a variety of factors. Age is one of the biggest factors affecting titration at Dr. Greenwood's surgical center. "Patients are comfortable, relaxed, but can still follow instruc- tions if needed, such as turning their head or looking to the side during various MIGS procedures," Dr. Greenwood said about the melt, which has a quick onset and a stable and consistent level of sedation throughout procedures. Dr. Berdahl has found patients given the melt tend to "gaze at the light and keep their eye more still at the time of surgery." Additionally, the elimination of the need to remove an IV, a smooth patient recovery, and their ability to quickly leave the postop area once all assessments are met are other advantages Dr. Berdahl sees. have a tendency to look at the light more and squint less during the surgery period. The ketamine also provides a mild euphoria, which from surgical experience is better for the patient." Dr. Berdahl, who uses MKO Melt in more than 99% of his cat- aract patients, doses primarily by age with consideration of ways to plan for anxiety level and prior use of sedatives. For the vast majority of patients—including high-risk patients—he does not start an IV. However, if the patient has a very high level of anxiety, Dr. Berdahl will saline lock an IV as a backup in case it's needed. Advantages The advantages of MKO Melt seen by Chris Bender, CRNA, in private practice, Sioux Falls, South Dakota, are that it can be used without start- ing an IV and to help start an IV in the case of a severe needle phobia. Because the melts are given earlier in the preop area and have a slower onset than IV medications, by the time patients are transport- ed to the operating room, they are comfortable and less able to "ramp up" their anxiety, which leads to a smooth overall experience, Mr. Bender said. Products that could change how you practice • September 2018 MKO Melt for cataract anesthesia MKO Melt Source: Chris Bender, CRNA AT A GLANCE • MKO Melt can be used both without starting an IV and to help start an IV. • It can prevent a preop "ramp up" of patient anxiety and allow a smoother overall experience. • The primary disadvantage is the difficulty to redose or supplement the sedation once the procedure is started.

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