Eyeworld

6 | SUPPLEMENT TO EYEWORLD | DECEMBER 2019 improving the cataract patient experience: Minimizing pain and inflammation while reducing the need for topical drops Denise Visco, MD, MBA Intracameral ketorolac/phenylephrine improves surgical experience T o minimize postop topical eye drops, I take a num- ber of approaches, but intracameral phenyleph- rine 1.0%/ketorolac 0.3% has had significant benefits for my patients. I actually do not use topical or injected steroids. Clinical evidence Intracameral phenylephrine/ ketorolac, which is added to the irrigating solution during cataract surgery, maintains iris tone during cataract surgery, prevents intraoperative floppy iris syndrome, maintains pupil dilation better than epineph- rine, and decreases surgical complications. 1,2 An additional indication is that it reduces pain. In research by Hovanesian et al., 7% of patients in whom this formulation was used vs. 14% of patients receiving placebo reported moderate or severe pain. 3 It also significantly decreased the use of narcotics at the time of cataract surgery. By Denise Visco, MD, MBA Patient experience with intracameral phenylephrine/ketorolac vs. topical loteprednol for 4 weeks 0.2% CME Rebound Iritis Pain/ Photophobia 1.9% 4.3% 1.7% 5.8% 0.6% Intracameral phenylephrine/ketorolac Loteprednol Conclusion In my practice, intracameral phenylephrine/ketorolac has re- sulted in a better patient expe- rience, with less pain, and it has reduced the need for analgesics. In addition, patients have better vision on postop day 1 and we use fewer drops after surgery. All of these benefits indi- cate that intracameral phenyl- ephrine/ketorolac is good for the surgeon and good for the patient. n References 1. Silverstein SM, et al. Effect of phenylephrine 1.0%-ketorolac 0.3% injection on tamsulosin-associated intraoperative floppy-iris syndrome. J Cataract Refract Surg. 2018;44:1103– 8. 2. Rosenberg ED, et al. Visual outcomes, efficacy, and surgical com- plications associated with intracameral phenylephrine 1.0%/ketorolac 0.3% administered during cataract surgery. Clin Ophthalmology. 2017;21–8. 3. Hovanesian JA, et al. Intracameral phenylephrine and ketorolac during cataract surgery to maintain intraoper- ative mydriasis and reduce postopera- tive ocular pain: integrated results from 2 pivotal phase 3 studies. J Cataract Refract Surg. 2015;41:2060–8. Dr. Visco is medical director and founder of Eyes of York Cataract & Laser Center in York, Pennsylva- nia. She can be contacted at dvisco@ eyesofyork.com. Most intraoperative approaches for mydriasis and pain use off-label applications or compounded medications. I prefer not to use compounded medications because of poten- tial risks. Retrospective investigation Taking a look at patients' surgical experience, we retro- spectively reviewed pain and inflammation in 2,277 eyes in our practice that had cataract surgery. A topical nonsteroidal anti-inflammatory was used 2 days before surgery and 10 weeks postop in all patients. Group 1 received intracamer- al phenylephrine/ketorolac, whereas Group 2 received a 4-week tapered dose of loteprednol. Patients in Group 1 had less pain and photophobia, half the incidence of rebound iritis, and one-third the incidence of cystoid macular edema (CME) compared with Group 2. I did not expect to see such a signif- icant difference. In fact, when we began using intracameral phenylephrine/ketorolac in- stead of the topical steroid with our regimen, I expected I could have more problems, not less. In addition, by switching to intracameral phenylephrine/ ketorolac, we eliminated 196 drops per eye.

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