Eyeworld

EW CATARACT 27 July 2015 to add a compounded agent in the OR—typically a mixture of epineph- rine and/or lidocaine," Dr. Holland said. While these are helpful and effective, federal regulations are increasingly restricting their use. "Some hospital-based surgical cen- ters are not allowing compounded substances to be used," he said. "In the past we have depended on com- pounded epinephrine and lidocaine, but that may not be available in the future." Newest mydriatic agent Dr. Holland thinks the newest agent on the market solves a lot of these issues—the FDA-approved Omidria. This is a combination of the NSAID ketorolac and phenylephrine, Dr. Holland explained. "This product is FDA-approved for maintaining pupil size by preventing miosis and for reducing postoperative pain in sur- gery," he said. It is not compounded and is already FDA-approved to add to the bag or bottle, he said. It is preservative- and bisulfite-free and has been found to be more effective than agents practitioners are cur- rently using. "In the clinical trials, Omidria was compared to phenyl- ephrine alone and ketorolac alone. The Omidria combination product was significantly better than either agent alone," he said. "It is import- ant to note that phenylephrine is known to be better than epineph- rine so we can assume that Omidria will be superior to intracameral epinephrine. "I've been able to use Omidria since it has been FDA-approved, and I think that it's the best agent added intracamerally to prevent miosis and reduce postoperative pain," Dr. Holland said. Dr. Donnenfeld pointed out that if the pupils are dilated before sur- gery, the dilation is generally main- tained unless inflammatory agents like prostaglandins are released. These will induce pupillary constric- tion, he explained. "That's why not only is it important to dilate the patient with dilating agents, it's also important to use a nonsteroidal to protect the eye from the production of prostaglandins and the pupil- lary constriction that occurs with their release," Dr. Donnenfeld said, adding that such nonsteroidals are the key to maintaining pupillary dilation throughout the case. The problem with nonsteroidals given preoperatively, however, is that these are irrigated out during the surgery with the balanced salt solution. "Omidria with the addi- tion of phenylephrine and ketorolac allows the infusion of nonsteroidal into the eye during the surgery, and that is extraordinarily effec- tive at maintaining pupil size," Dr. Donnenfeld said. "The nonsteroidal that is infused during the surgery protects the patient and the physi- cian from pupillary constriction." Dr. Donnenfeld views the approval of Omidria as a landmark moment in ophthalmology. "This is the first time we have an intraca- meral FDA-approved medication to be used routinely during cataract surgery," he said, adding that the future of cataract surgery will be drug delivery. In the future he believes the use of drops is going to be diminished, with Omidria paving the way. "We're going to look back on that and say, 'That's what started the trend,'" Dr. Donnenfeld said. He is hopeful that the nonsteroidal may prove helpful as well, potentially reducing the risk of macular thicken- ing. "I believe that placing the med- ication into the eye from surgery is going to provide an additional value in obtaining macular function," Dr. Donnenfeld said. EW Editors' note: Dr. Donnenfeld has financial interests with Alcon, Allergan (Irvine, Calif.), Bausch + Lomb (Bridge- water, N.J.), and Omeros. Dr. Holland has financial interests with Omeros. Contact information Donnenfeld: ericdonnenfeld@gmail.com Holland: eholland@holprovision.com DIGITAL.OPHTHALMOLOGYBUSINESS.ORG

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