Eyeworld

24 | EYEWORLD | JULY 2019 ATARACT C PHARMACEUTICAL FOCUS by Maxine Lipner EyeWorld Senior Contributing Writer Contact information Dhaliwal: dhaliwaldk@upmc.edu Hardten: drhardten@mneye.com Miller: miller@jsei.ucla.edu The literature indicates that about one in three patients is sensitive to prolonged steroid use and will experience a pressure spike, Dr. Miller said. Young myopes have a higher suscep- tibility and must be monitored more closely. At the 2-week postoperative mark, he finds that a small number of patients—usually those who have pre-existing glaucoma—will have a pres- sure issue. Even with the risk of a pressure rise, it's more important to control inflammation and make sure patients don't develop macular edema since glaucoma drops can always be added to the regimen to control pressure, he stressed. His go-to glaucoma drop is dorzolamide/timolol. "In general, the more potent the steroid, the more it will penetrate the eye and the higher the risk of a pressure spike," Dr. Miller said, adding that difluprednate would have the greatest risk and fluorometholone the least. Dr. Miller does not currently inject steroids, citing that while there is plenty of good literature to support the injection of antibiotics, the same is not yet true for steroids. "If you have a pressure spike after you inject a corticosteroid, it's much harder to deal with because you have to wait for the ste- roid to go away from inside the eye," he said. Deepinder K. Dhaliwal, MD, also uses prednisolone acetate 1%, advising patients to take it every couple of hours the day of surgery and then four times a day for 1 week. She tapers this by 1 drop for the next 3 weeks. "When I C ataract surgery today is usually topped off with a steroid, but there are myriad approaches. EyeWorld asked several leading ophthalmologists to share their steroid regimens. David Hardten, MD, typically utilizes prednisolone acetate drops in combination with an NSAID. "There's a signif- icant number of patients who I think will have quicker recovery and less irritation and pain by also utilizing steroids," he said. He usually places patients on a steroid four times a day for 1 week and then two times a day until the bottle runs out. However, in cases where there is a lot of inflammation after the surgery, when the patient has the second eye done, Dr. Hardten may ei- ther prescribe a higher concentration or recom- mend taking the medication more frequently. If the patient experiences a pressure spike, Dr. Hardten may lower the frequency of the steroid dosing or select another medication. However, in the rare case where the pressure is extremely high, Dr. Hardten would add a medi- cation to lower it. In some high-risk patients with a history of CME in the other eye or who are receiving VEGF injections for diabetic macular edema, Dr. Hardten may give a subconjunctival injec- tion of triamcinolone acetonide. Typically, he prefers not to use this approach because of the discomfort of the injection as well as concerns that the medication cannot be removed if there is a pressure spike. In cases where he uses triam- cinolone acetonide, the patient is also placed on standard postoperative drops or possibly on an accelerated topical steroid regimen. Kevin M. Miller, MD, usually prescribes prednisolone acetate 1% drops four times a day for 4 weeks. Some exceptions to his typi- cal post-cataract steroid regimen include cases of HLA-B27 uveitis and juvenile rheumatoid arthritis. He puts such patients on steroid drops a week before surgery four times a day and then after surgery every 2 hours while awake to keep inflammation in check. He prescribes NSAIDs only for eyes that are at high risk for developing postoperative cystoid macular edema, which is about 2% of the population. Using steroids for cataract surgery About the doctors Deepinder K. Dhaliwal, MD Professor of ophthalmology University of Pittsburgh School of Medicine Pittsburgh David Hardten, MD Minnesota Eye Consultants Minneapolis Kevin M. Miller, MD Kolokotrones Chair in Ophthalmology David Geffen School of Medicine at UCLA Los Angeles Financial interests Dhaliwal: Ocular Therapeutix Hardten: None Miller: None "There's a significant number of patients who I think will have quicker recovery and less irritation and pain by also utilizing steroids." —David Hardten, MD continued on page 26

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