Eyeworld

EW CATARACT 61 March 2017 For patients who have a bad uveitic cataract, he may also use oral steroids to help keep this from flaring up from the surgery. "On them I'll do belt and suspenders," Dr. Devgan said. Such patients will get the cataract surgery done with Triesence or triamcinolone in the anterior chamber and have some kind of dexamethasone subconjunc- tivally. On the OR table they may have some IV steroids, or he'll give them oral steroids for the first week postop, and they'll also get topical steroid drops postoperatively. Although most patients won't need oral and subconjunctival steroids, some patients may need more steroids than others. Those with underlying conditions such as diabetes may be in this category, he finds. "Sometimes diabetic patients are prone to more swelling and need more anti-inflammatories," Dr. Devgan said, adding that likewise in cases with more involved cataract surgery or denser cataracts, more steroids would be warranted. What's more, it's important to take the patient's background into account since different populations have different inflammatory re- sponses. Dr. Devgan notes that he, as an American whose family hailed from India, with a brownish skin tone, is more apt to need greater amounts of steroids. "We definitely see certain populations of patients, in general, with increased pig- mentation who tend to have more inflammation," Dr. Devgan said. This may mean that a patient with increased pigmentation may need to be on steroids longer. While some fair-skinned patients may be free from inflammation within 2 weeks, a patient with a darker complexion who undergoes surgery done by a resident may still be on steroids for 2 months after surgery. Dr. Devgan looks forward to the day when such postoperative drops are a thing of the past. "What I would love to see in the future is ac- tually a depot injection of some sort of steroid and then no drops needed in the postoperative period," Dr. Devgan said. However, this is not yet possible, which means that patients still need to receive steroids as well as nonsteroidal anti-inflammatory drugs and antibiotics in the postop- erative period, he concluded. EW because the intracameral steroids/ antibiotics are not reimbursed, he tends to limit use of this approach to those he's concerned won't do well without it. "I definitely offer it to patients I think are going to be noncompliant with their drops," Dr. Hoffman said, adding that this might potentially include an Alz- heimer's patient or one who cannot afford medication. There are other steroid options as well. Dr. Hoffman avoids use of oral steroids because he doesn't be- lieve they are needed. "If you've got enough inflammation and you need to put a patient on oral steroids, you need to think about infection," Dr. Hoffman said. He does, however, think that there's a role for subcon- junctival steroids. While he doesn't think that this is needed routine- ly at the end of cataract surgery, for those who are uncomfortable putting intracameral steroids in the eye, this is an option. Dr. Hoffman cautions, however, that one of the issues with using a long-acting depot steroid is that if they are a steroid responder, it takes 3 to 4 months for that depot steroid to get absorbed. "That's one reason why I tend not to use subconjunctival steroids in just routine cataract surgery," he said. "First of all, it's not needed; sec- ond of all, if the person is a steroid responder, then you may have to excise the steroid if they are very sensitive." However, a short-acting steroid such as Decadron (dexameth- asone, Merck, Whitehouse Station, New Jersey), might be warranted, Dr. Hoffman continued. He himself uses this approach when dealing with a complicated anterior segment case such as sewing in a lens or doing a pupilloplasty. Meanwhile, Dr. Devgan be- lieves that there is a role for both subconjunctival and oral steroids. There are instances at the county hospital where he may use these on certain resident cases or in instances where there is a lot of manipulation or a complication. "I do a cataract surgery in a few minutes, but the resident may take an hour," Dr. Devgan said. "So, the eyes are going to look more beat-up the next day and will take more time to recover." In such cases, he injects dexameth- asone subconjunctivally, which he finds lasts for at least a few days if not a week or two. Editors' note: Dr. Devgan has financial affiliations with Alcon. Dr. Hoffman has no financial interests related to his comments in this article. Contact information Devgan: devgan@gmail.com Hoffman: rshoffman@finemd.com

• Blank Page
• Blank Page (1)