Eyeworld

EW CATARACT 34 December 2016 Pharmaceutical focus by Maxine Lipner EyeWorld Senior Contributing Writer it." This frees up the nursing staff and offers more flexibility to the practitioner. "If you are delayed, that means the preparation of the patient will not be as good as doing the in- jection at the proper time during the surgery," she said, adding that this intraoperative approach is fast and the predicted effect is quite efficient. In addition, there is a money- saving aspect, Dr. Cochener contin- ued. "You are avoiding the addition- al time dedicated to the nurse who needs to prepare patients before," she said. "I think that in this new strategy, [physicians] are going to be able to better reach the efficacy they are looking for with the concept of 'fast-track sutureless' management of patients, targeting improved efficacy but also safety." With the intracameral approach, physicians reduce toxicity to the ocular surface by decreasing the number of drops on the surface of the eye, Dr. Cochener pointed out. Using fewer drops could prevent ocular surface disease from occurring and persisting days after the surgery. Postoperatively, the rate of dryness after cataract surgery has been close to 20%. "Respecting the ocular sur- face in a better way will potentially help decrease the number of ocular surface problems after surgery," she said. Dr. Findl agreed, noting that some patients have a hypersensi- tivity to the preservatives in drops. While it is possible to get most drops preservative-free, there is a cost factor. Dr. Labetoulle pointed out that drops may also cause some systemic issues. "There may be some side ef- fects because of the systemic passage of the drugs into the blood," he said. For example, patients may have occurrences of high blood pressure, increased heart rate, or malaise due to side effects. He views the use of the intra- cameral approach as beneficial in reducing patient anxiety. "With the usual eye drops, patients have to come in early, prior to surgery, and then when they arrive at the surgery area everyone is looking at the pupil to make sure that it will be dilated by the time of surgery," Dr. drops and you need to do that on a regular basis—not just once but several times," Dr. Findl said, adding that ideally you leave a few minutes between drops so that they can take full effect. In addition to dilating drops, there is a local anesthetic and an NSAID before surgery. That means returning to the patient on a regular basis to check on or give more drops, which requires the needed personnel. "The other option is not to give any drops, just some local anesthetic drops before surgery and then do the rest on the table," Dr. Findl said. With the intracameral Mydrane approach, pupil dilation can be rap- idly attained during the procedure, according to Beatrice Cochener, MD, PhD, Brest University Hospital, Brest, France. With a normal pupil in the Mydrane study, investigators were able to attain rapid dilation. "We were able to demonstrate that you achieve the dilation in less than a minute with a mean efficacy of a few seconds to get the dilation good enough in one single injection," Dr. Cochener said. "You will be able to get the effect as soon as you want question of mixing this on the table and getting the dilution right. With Mydrane, which is now on-label in Europe, this is not an issue. "There was a proper large trial, which has some sound evidence," Dr. Findl said. He also likes the fact that tropicamide is included in Mydrane, which had rarely been used intracamerally before but is quite effective, he noted. Mydrane is not as long-lasting as some drops given before surgery, which can take considerable time to wear off. "These patients often still have a di- lated pupil for 1 to 2 days if they're unlucky," Dr. Findl said. Intracameral advantages There can be some drawbacks with drops, said Marc Labetoulle, MD, PhD, head of the ophthalmology department, South Paris Universi- ty Hospital, Paris, France. "When you use eye drops first it is very time-consuming for the surgical team because you have to instill the drops at least 30 to 60 minutes be- fore the surgery," Dr. Labetoulle said. Dr. Findl agreed that time is an issue here. "Someone needs to apply Considering intraocular injection of mydriatics A ttaining proper pupil di- lation is an intrinsic part of cataract surgery. While traditionally this has been achieved with the aid of drops, some are now moving to intraocular injection of mydriatics, thanks to the recent European ap- proval of Mydrane (phenylephrine [0.31%], tropicamide [0.02%] and li- docaine [1%], Thea Pharmaceuticals, Newcastle under Lyme, U.K.). Others have used this off-la- bel for some time with the aid of drugs such as lidocaine 1%, phen- ylephrine, and diluted epinephrine, according to Oliver Findl, MD, Department of Ophthalmology, Hanusch Hospital, Vienna, Austria. There was also the "Shugarcaine" intracameral cocktail, which includ- ed a mixture of epinephrine and lidocaine, put forth by the late Joel Sugar, MD, Dr. Findl said. "But it was off-label, and some hospitals have issues with that in general," he said. In addition, there was the Dialing in on dilation Resources impact with Mydrane Source: Beatrice Cochener, MD, PhD

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