Eyeworld

by Francis Mah, MD Innovative ophthalmic drug-delivery approaches, intraoperative anti- inflammatories, and future development In phase 2 and both phase 3 trials, there was a significant dif- ference in the absence of pain on postoperative day 8 with the treatment compared with the placebo; in the phase 2 trial and first phase 3 trial, there was a significant difference in the absence of inflammatory cells on day 14 with the treatment compared with placebo. 9 A recently approved brom- fenac 0.075% preparation was Novel drug-delivery plat- forms are proceeding through the approval process. One prod- uct is a sustained-release, resorb- able dexamethasone depot that is placed in the canaliculus of the eyelid. The hydrogel deliv- ery vehicle with dexamethasone is inserted in the vertical cana- liculus. It swells on contact with moisture and expands until firmly secured in the canalicu- lus. It is designed to remain for 30 days and beyond. Drug-delivery advances A new phenylephrine 1%/ke- torolac 0.3% Food and Drug Administration-approved drug-delivery option is avail- able. Studies have shown that it helps prevent miosis during cataract surgery, reduces post- operative pain, and is safe and well-tolerated. 4,5 In a retrospective case re- view of 641 cataract procedures, 260 procedures were performed with intracameral phenyleph- rine/ketorolac and 381 were performed with intracameral epinephrine 1 mg/mL. 6 Intraca- meral phenylephrine/ketorolac decreased intraoperative and postoperative complications and pupillary dilating device dependence, improved best corrected visual acuity, and reduced procedural time com- pared with intracameral epi- nephrine alone. We also have a number of other intracameral and inject- able compounded medications from compounding pharmacies. A study of 2,300 eyes was per- formed to review transzonular injection of the steroid/antibi- otic combination of triamcin- olone and moxifloxacin with and without vancomycin to reduce the use of drops postop- eratively; 19% of the patients also received supplemental topical NSAIDs, no patients de- veloped endophthalmitis, and cystoid macular edema (CME) developed in 2%. 7 This work was confirmed by a study from James Lewis, MD, who also found a CME rate of 2% when transzonular triamcinolone was used in place of topical anti- inflammatory medications. 8 Emerging drug-delivery options may improve patient compliance and outcomes A lthough anti-inflam- matory eye drops reduce inflamma- tion and pain after cataract surgery, a number of issues may limit their efficacy. Innovative new drug-delivery options are emerg- ing that may help us control pain and inflammation more effectively. Limitations of current options Problems with topical drops may include noncompliance, man- ual dexterity difficulties, ocular surface toxicity from traditional preservatives, inconsistent pene- tration into the eye, and cost. Multiple studies have re- ported noncompliance and self-administration difficulties with topical medications among cataract surgery patients. 1,2 A 2014 study showed that 92.6% of patients incorrectly ad- ministered topical medications after cataract surgery. 3 continued on page 6 Francis Mah, MD " We have a variety of excellent choices to help improve patient compliance and surgical outcomes. " –Francis Mah, MD Dr. Mah's perioperative inflammation regimen High-risk CME patients • Topical nepafenac 0.3% 3 days preoperatively • Topical difluprednate 0.05% and nepafenac 0.3% for 3 months Routine cataract • Intracameral compounded dexamethasone and moxifloxacin • Topical difluprednate 0.05% QD and nepafenac 0.3% QD for 4 weeks • If cost is an issue, compounded drops • Prednisolone phosphate/ketorolac taper Supported by Alcon Laboratories, Bausch + Lomb, Imprimis Pharmaceuticals, Ocular Therapeutix, and Omeros Corporation 5

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