EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/78710
34 EW FEATURE Bucking continued from page 33 February 2011 Perioperative pharmacology May 2012 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. patients dealt with the burdensome drop schedule. His decision was also influenced by regulatory factors bearing down. One was the adoption of the single- use, single-patient mandate. That dictates that even a big container of medication must be used for a single patient. In addition, he was troubled by compounding regulations con- cerning the number of medications that could be used in the OR. "Any time you mix three medicines to- gether it becomes compounding," he said. Dr. Liegner saw this as a potentially looming problem. With this in mind Dr. Liegner reached out to fellow practitioners at ASCRS asking for ideas. One practi- tioner mentioned that he had been injecting steroids into the eye. This made sense to Dr. Liegner. "In my mind the reason is because when we send patients to the retina special- ists, they're injecting triamcinolone into the vitreous as one of the high- est levels of aggressive management of CME," Dr. Liegner said. Dr. Liegner is now doing this prophylactically in every case and has watched his CME rates plum- met. "When I look inside the eye there is a big dollop of steroids sit- ting south of the macular, and I'm sure that it has had a positive influ- ence on the rate of CME," he said. While Dr. Liegner had done close to 400 cases with the approach in 2011, it wasn't until November that he found himself with a CME case. "I said, 'Gosh, I haven't seen one of those in a long time,'" he said. With the approach, Dr. Liegner has arranged for an accredited PACB pharmacy to compound the medi- cine. Then a 27-gauge cannula con- taining the triamcinolone and moxifloxacin (Vigamox, Alcon, Fort Worth, Texas) is injected into the vitreous cavity where it becomes a steroid depot. Dr. Liegner finds that in 94% of patients, this injection alone is enough to suppress inflammation without supplemental NSAID or steroid suppression. "That means that 94% of people never buy eye drops," he said. When the other 6% have breakthrough, he gives them prednisolone for about 2 weeks. The only major complication has been one case of endophthalmi- tis, which may or may not be related to the approach. "I'd never had an episode of endophthalmitis so it's hard to know whether it's just the luck of the draw or something about this," Dr. Liegner said. Boon for patients Meanwhile, Dr. Liegner feels that the NSAID-free approach has been a boon for patients. He cited the eco- nomics of the situation. "Eye drops cost probably $200—if you look at the fancy steroid and then the fancy non-steroidal that's $300," he said. "The cost of this ends up being about $1.20-1.60 per patient." A key reason it's so inexpensive is that since it is compounded, it can come in a multi-dose vial. "I can treat up to 20 patients with this multi-dose vial—the day's worth of cataract," Dr. Liegner said. He also sees it as a savings in terms of nurses' wages since they no longer have to spend time telling patients about their medication. There has also been one unex- pected benefit to leaving NSAIDs out of the regimen. "Unexpectedly and very positively it turns out that there is a tremendous amount of previously unrecognized drop anxi- ety," Dr. Liegner said. "People are hiding—they don't want to do cataract surgery because they can't put eye drops in their eyes." Dr. Liegner doesn't think that it will be long before most practition- ers are saying no to NSAIDs and leaving these behind when it comes to concerns about CME. "I think in 4 years everyone is going to be doing this," he said. He worries, however, that this may eventually erode the advantage. "I think that it's going to become such an impor- tant thing that someone is going to create this drug so that we can put it in the eye," he said. This, he feels, will cost more money and like the NSAIDs will be single-dose delivery. "The power of this is to have a multi-dose vial," he said. "If [we] lose the multi-dose vial, the advan- tage of this goes away." EW Watch this video on your smartphone or iPad using your QR code reader. (Scanner available for free at your app store.) Jeffrey Liegner, M.D., demonstrating trans-zonular intravitreal injection of triamcinolone and moxifloxacin after IOL insertion in lieu of pre-op/post-op eye drops Editors' note: Dr. Liegner has no finan- cial interests related to this article. Contact information Liegner: 973-729-5757, liegner@embarqmail.com