Eyeworld

EW CATARACT 24 November 2018 Pharmaceutical focus by Maxine Lipner EyeWorld Senior Contributing Writer using the intraocular injection ap- proach due to the fact that Imprimis is a reputable 503B compounding pharmacy. "We've done 10,000 of these injections and haven't had a TASS outbreak or an issue with it," he said. "I think there is risk, but it's tiny." P. Dee Stephenson, MD, asso- ciate professor of ophthalmology, University of South Florida Col- lege of Medicine, Tampa, Florida, usually relies on drops. "About 3 days before surgery, patients are on Besivance BID [besifloxacin, Bausch + Lomb, Bridgewater, New Jersey], BromSite BID [bromfenac, Sun Phar- ma, Mumbai, India], and Lotemax [loteprednol, Bausch + Lomb]," she said. "Intraoperatively, I still use vancomycin in the bottle," she said, stressing that she's never had any issue occur with it. Postoperative- ly, her regimen includes Besivance twice a day for 2 weeks, BromSite twice a day for 6 weeks, and Lote- max four times a day for 1 week, tapered by giving one drop less over the next 6 weeks. In patients for whom cost is a concern, Dr. Stephenson will pre- scribe a compounded Imprimis drop of all three medications in the same bottle. In certain high-risk cases, such as someone with advanced glaucoma or uveitis, she will give patients moxifloxacin intracamer- ally. Some who have insurance that covers their topical drops prefer to use this. "A lot of older patients, if they have to pay $90 and their copay is $20, they're not going to do it if it doesn't go toward their de- ductible, medication, or anything," she said. She doesn't typically use in- jections for several reasons. "I do a lot of accommodative lenses and I don't like doing a blind stick and sticking medicine inside the eye because it increases the volume and I'm not sure where that lens would go," Dr. Stephenson said. When it comes to HORV, Dr. Stephenson acknowledged that this is a terrible retinal issue, but said she thinks there may be some exten- uating circumstances with regard Cataract surgeons weighing use of less topical medication S ome practitioners today have moved away from having patients use a plethora of drops for cataract surgery to other approaches that minimize or even look to do away with these altogeth- er. EyeWorld asked several leading ophthalmologists about their cur- rent regimens. John Berdahl, MD, associate professor of ophthalmology, Univer- sity of South Dakota Medical School, relies on a combination medication preoperatively and postoperative- ly, which includes Pred-Gati-Brom (prednisolone acetate/gatifloxacin/ bromfenac, Imprimis, San Diego) once a day for 3 days before cataract removal and once a day for a month after surgery. During the proce- dure, he injects a small amount of Dex-Moxi-Ketor (dexamethasone/ moxifloxacin/ketorolac, Imprimis) subconjunctivally into the anterior chamber. "Patients get an intracam- setting where sometimes it's hard for patients to get back to us, we think having a once-a-day drop to help prevent rebound inflammation is helpful," he said. "But I wouldn't say that it's wrong to do a totally dropless approach." His current regimen has evolved from one he used just 3 or 4 years ago when he started using intraca- meral antibiotics and was injecting into the vitreous at the time. The regimen then included vancomycin, moxifloxacin, and triamcinolone, he explained. "It worked well but we would have floaters and we would disturb the vitreous body," Dr. Berdahl said. "Now we inject into the anterior chamber and there are no floaters, so we think that this is a more patient-centric approach, while still accomplishing the goal of delivering intraocular medication." The regimen also no longer includes vancomycin, which Dr. Berdahl stopped using because of concerns over hemorrhagic occlu- sive retinal vasculitis (HORV). "It does appear that it is linked," he said. Dr. Berdahl, though watchful for TASS, is more confident about eral steroid, antibiotic, and NSAID at the time of surgery and they get a once-a-day drop for a month," Dr. Berdahl said. In his view, the benefits of the approach are great, with data indi- cating that intraocular antibiotics lower the rate of endophthalmitis. He finds that with a steroid inside the eye the corneas look better on postoperative day 1. While one of the concerns of using an intraocular steroid is that there may be an IOP spike, Dr. Berdahl has not found this. 1 "We studied that carefully in glaucoma patients who had stents placed and we didn't find any in- crease in IOP spikes," he said. In addition to the steroid effect of clearing the cornea and the anti- biotic protection, the NSAID plays a role, according to Dr. Berdahl. "We think that NSAIDs help with com- fort and preventing CME postopera- tively," he said. While Dr. Berdahl thinks that it would be reasonable to take an entirely dropless approach, relying strictly on intraocular antibiotics didn't seem practical in his prac- tice. "Because we practice in a rural Dropping drops? Injection of dexamethasone/moxifloxacin/ketorolac into the anterior chamber after cataract surgery Source: John Berdahl, MD

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