EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/78710
May 2012 Perioperative pharmacology February 2011 EW FEATURE 33 Bucking the drop trend by Maxine Lipner Senior EyeWorld Contributing Editor AT A GLANCE • A confluence of factors including expense, compliance issues, and regulatory reasons has spurred one practitioner to adopt an NSAID-free approach for avoiding CME • By injecting triamcinolone into the vitreous cavity, he finds it is possible to suppress inflammation in most cases • With the approach, unexpected drop anxiety has come to light; there are patients who are avoiding cataract surgery due to fear of placing drops in their eyes Saying no to NSAIDs in cataract patients W hile most practition- ers tout the value of NSAIDs for keeping cystoid macular edema (CME) in the wings, not everyone prizes these for staving off the condition. One prac- titioner, Jeffrey T. Liegner, M.D., Eye Care Northwest, Sparta, N.J., re- cently tossed these in the proverbial bucket, at least for cataract patients, in favor of another approach that he sees as sparing patients' expense and aggravation, while still keeping CME Groundswell continued from page 32 rious consequences. Just a little bit of macular edema might tip a Tecnis Multifocal (Abbott Medical Optics, AMO, Santa Ana, Calif.) or a ReSTOR lens (Alcon, Fort Worth, Texas) away from success. The cost factor Dr. Wittpenn views the data here as helping to elucidate the economics involved. "I understand that every- thing is a risk-benefit choice, an economic choice, but at least your patients can make the choice of whether reducing the risk from 2.5% definite CME or perhaps 12% of some measureable effect on the macular down to 0-4% is worth the $200 it is going to cost your patients to buy the medicine," he said. CME is also very difficult to treat, pointed out Keith Walter, M.D., associate professor of ophthal- mology, Wake Forest University, Winston-Salem, N.C. "Once it's there it is hard to get rid of," Dr. Walter said. "Some people need very expensive long-term treatment." This can come in the form of steroid injections inside of the eye or the Ozurdex implant (Allergan, Irvine, Calif.), which Dr. Walter pointed out can be about $800 for each implant. By comparison the NSAID is a bar- gain. "One bottle of Bromday [bromfenac, ISTA Pharmaceuticals, Irvine, Calif.] retails for about $160, but with insurance it can be as low as $6 for a bottle," he said. "The most I've seen patients pay is about $50 for a co-pay." Deliberating the regimen Frequency of recommended NSAID use can fluctuate. This varies de- pending upon which non-steroidal you're using, Dr. Gayton pointed out. "If you're using Nevanac [nepafenac, Alcon], it should be given three times a day, and if you're using diclofenac or ketorolac [Acular, Allergan], they should be given four times a day," he said. "But if you're using Bromday, it should be given only once a day." Dr. Raizman stressed that NSAIDs in the approval process haven't been studied for CME but rather for inflammation. "For the prevention of CME, I don't know the right dose, but I'd rather err on the side of using a slightly higher dosing schedule," he said. "I'm not currently [dosing] once a day with any of the products regardless of what the label is for post-cataract in- flammation." Overall, Dr. Wittpenn believes that NSAIDs have a role in cataract surgery for all patients. "If I was having my own eyes operated on I would use a non-steroidal, and I would use a brand non-steroidal [see sidebar]," he said. "If that's what I would do with my own eyes, that is what I recommend to my patients." EW Editors' note: Dr. Gayton has financial interests with Alcon and ISTA Pharma- ceuticals. Dr. Raizman has financial interests with Alcon, Allergan, Bausch + Lomb (Rochester, N.Y.), and ISTA. Dr. Walter has financial interests with ISTA and Merck (Whitehouse Station, N.J.). Dr. Wittpenn has financial inter- ests with Bausch + Lomb and ISTA. Contact information Gayton: 478-923-5872, jlgayton@aol.com Raizman: 617-314-2656, mbraizman@eyeboston.com Walter: 336-716-4091, kwalter@wakehealth.edu Wittpenn: 631-941-3363, jrwittpenn@aol.com at bay. His approach? Dr. Liegner protects his patients with intravit- real injection of steroids. This is a far turnaround for Dr. Liegner, who like many practitioners relied heavily on NSAIDs in many cataract cases. "I used to use NSAIDs for my multifocal IOLs, which make up probably 20-25% of the practice, because of the heightened pressure on us to have outstanding visual outcomes," he said. Taking a hard look All that NSAID fervor began to change a couple of years ago when a plethora of pressures pushed Dr. Liegner to look for alternatives. "It's a confluence of factors that led to this," Dr. Liegner said. One factor was the expense involved in using the NSAIDs. "The price of the med- ication was outrageous," he said. "The pharmaceutical companies stopped sampling medications in our office—we no longer had a pharmaceutical buffer against the expense." Dr. Liegner was also spurred by patient compliance issues with the NSAIDs, which were a concern. "By injecting it into the vitreous, com- pliance is no longer [an issue]," he said. In addition, he was apprehen- sive about how physically limited continued on page 34 With intravitreal injection of a long-acting steroid, NSAID use is a thing of the past, and CME rates have plummeted for one practitioner Source: Jeffrey T. Liegner, M.D.