Eyeworld

EW FEATURE 56 Steroids roundup • August 2017 AT A GLANCE • Steroid preferences, drop regimens, and delivery methods vary among physicians. • Some start steroids before surgery and continue them for several weeks postop, while others stick to a postop regimen only. Some are strictly topical, while others use an injected component. • New drug delivery options aim to reduce or eliminate the need for topical drops. • Safety and efficacy data, economics, and patient convenience play a role in physicians deciding the best mode of drug delivery for their patients. by Liz Hillman EyeWorld Staff Writer Physicians discuss their corticosteroid regimens for routine and non-routine cataract surgery, drug delivery options, and more I n its updated Cataract in the Adult Eye Preferred Practice Pat- tern guidelines, the American Academy of Ophthalmology (AAO) Cataract and Anterior Segment Panel wrote that physi- cians' usage pattern and mode of delivery of antibiotic, steroid, and nonsteroidal anti-inflammatory drugs (NSAIDs) varies. 1 it came to branded vs. non-branded medications, about 51% of respon- dents to the survey said their ocular prescriptions were branded. John Hovanesian, MD, Harvard Eye Associates, San Clemente, Cal- ifornia, said he begins steroids and nonsteroidals 3 days preop, continu- ing the steroid four times a day for 3 weeks postop, cutting it down to three times a day during the fourth week. Nonsteroidals are adminis- tered once a day for 4 weeks postop. He said he prefers branded prednisolone acetate but is willing to allow generic substitutes if that is the patient's preference. The reason? He said branded prednisolone ace- tate is a suspension, which he thinks is more consistent when it comes to dosing. When should corticosteroids be used—before, during, or after cat- aract surgery, or in some combina- tion thereof? How should a steroid regimen differ for a routine cataract patient compared to a non-routine case, such as a patient with diabetic eye disease or iridocyclitis? Does branded vs. generic matter? What role do NSAIDs play? What about delivery options other than topical drops—injection, punctal plugs, or slow-release implants? "There are no controlled investigations that establish opti- mal regimens for the use of topical agents. Therefore, it is the decision of the operating surgeon to use any or all of these products singly or in combination," the panel stated in the guidelines. The physicians that EyeWorld interviewed had some similarities but also some differences on this front, providing a range of thought on cataract surgery and steroid use. Who, what, and when? The 2016 ASCRS Clinical Survey, which included more than 1,500 unique respondents from the U.S. and around the world, found the vast majority of physicians use cor- ticosteroids in some capacity before, during, or after cataract surgery. For standard cataract cases, slightly more than 30% of U.S. respondents to the survey said they prescribe topical steroids at least 3 days preop; 72% said they prescribe them for at least 3 days postop. On that front, most (65%) recommend steroid drops for 4 weeks postop for the majority of cataract patients. About two-thirds of respondents reported that their primary goal with the steroid is to reduce anterior chamber inflammation; about 69% said they use NSAIDs for cystoid macular edema (CME) prophylaxis. The majority of respondents think that using both a corticosteroid and NSAID is important for inflamma- tion and pain control postop. The survey also identified ge- neric prednisolone acetate 1% as the most commonly preferred topical steroid for routine cataract surgery among U.S. ophthalmologists, followed by difluprednate 0.05%. The preferred NSAID among respon- dents, overall, was nepafenac. When The who, what, where, when, why, and how of steroids and cataract surgery Dropless cataract surgery reduces or eliminates the post-cataract surgery drop routine. Source: John Gastaldo/Imprimis Pharmaceuticals Monthly Pulse Steroids roundup When you see a patient who requires topical steroids, which steroid would you consider using as your first line therapy? For patients who require long-term control of inflammation, which steroid-sparing agent have you used most commonly? EyeWorld Monthly Pulse is a reader survey on trends and patterns for the practicing ophthalmologist. Each month we send an online survey covering different topics so readers can see how they compare to our survey. If you would like to join the physicians who take a minute a month to share their views, please send us an email and we will add your name. Email carly@eyeworld.org and put "EW Pulse" in the subject line. Difluprednate Prednisolone acetate Dexamethasone Loteprednol NSAIDs Cyclosporine Tacrolimus Lifitegrast

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