Eyeworld

57 EW FEATURE August 2017 • Steroids roundup said he will still provide a steroid for a short period of time (a week or so). "A lot of times in cataract surgery now, if they do have a steroid response, those are glauco- ma patients that we're performing glaucoma or IOP-lowering proce- dures on as well, like an [endocyclo- photocoagulation] or a stent," he said, noting that he finds having a steroid on board in these cases is still appropriate. Where and how? While Drs. Hovanesian and Newsom discussed their practices for topical drugs and cataract surgery, John Berdahl, MD, Vance Thompson Vision, Sioux Falls, South Dakota, uses a "dropless" formulation of dexamethasone/moxifloxacin/ke- torolac (Dex-Moxi-Ketor, Imprimis Pharmaceuticals, San Diego) injected pars plana into the vitreous. "I like the intracameral anti- biotic and the fact that there's an NSAID present in the injection, but from a steroid perspective, it's clear, so patients don't experience float- ers like they do with triamcinolone injections," Dr. Berdahl said. While the dexamethasone wears off faster because it's a solution, not a suspension, he said this isn't a concern because despite the injec- tion, he still prescribes a once-a-day NSAID or a once-a-day NSAID/pred- nisolone/moxifloxacin combination drop. T. Hunter Newsom, MD, New- som Eye, Tampa, Florida, starts his steroid/NSAID/antibiotic regimen postoperatively, advising each be administered topically three times a day, assuming these drugs are gener- ics. Generics are "typically what we use and what most patients end up wanting and using." If the patient has a history of dry or irritable eye, Dr. Newsom said he will drop the NSAID or recom- mend branded Prolensa (bromfenac ophthalmic solution 0.07%, Bausch + Lomb, Bridgewater, New Jersey) or Ilevro (nepafenac ophthalmic suspension 0.3%, Novartis, Basel, Switzerland), which he said brings NSAID drops to just once a day. He noted that you have to be careful about insurance coverage and cost with these medications. While prednisolone is Dr. Newsom's steroid of choice in most cases, if the patient has iridocyclitis (uveitis), he will switch to Durezol (difluprednate ophthalmic emulsion 0.05%, Novartis) three to six times a day and the strongest NSAID once a day, depending on the patient's condition. Dr. Newsom noted that Prolensa or Ilevro as the NSAID at one drop per day might be easier on patients using Durezol at this higher frequency. The AAO guidelines recommend additional or oral corticosteroids for uveitis cataract patients, even if patients are on anti-inflammatory medication already. "The medical regimen should be individualized based on the severity and sequelae of past episodes of uveitis and the ease with which inflammation has been previously controlled," the panel wrote. Patients with diabetic retinop- athy having cataract surgery face a higher risk for CME. 2 The AAO guidelines state that CME, associated with post-surgical inflammation, can be prevented with anti-inflam- matories, and NSAIDs alone or with topical corticosteroids can decrease risk of postop CME. Dr. Hovanesian said he'll use a steroid and NSAID in diabetic patients to reduce CME risk and will continue it for 2–3 months after surgery. Dr. Newsom said retina spe- cialists in his practice watch these patients closely, keeping them on steroids and NSAIDs for a prolonged period of time. "If you're a diabetic and you have cataract surgery, we know cata- ract surgery is going to make diabet- ic retinopathy worse," Dr. Newsom said. "We have a lot of diabetics in our practice, so we're extremely ag- gressive at making sure we minimize any type of macular edema." The only time Dr. Newsom said he would consider dropping the steroid and using an NSAID alone would be if patients said they have an allergy and are adamant about not using steroids. In glaucoma patients, who might be at risk for an IOP spike with steroids, Dr. Newsom Dr. Berdahl said that his prac- tice made the switch to intravitreal injections of these drugs based on literature showing lower infection rates with intracameral antibiotics and due to a better patient experi- ence. "From the patient experience standpoint, the worst part of cata- ract surgery is the postop drops, and oftentimes it is the most expensive out-of-pocket part of cataract surgery for the patient," Dr. Berdahl said. "The confluence of those factors— good science supporting intraca- meral antibiotics, a better patient experience, and more favorable patient economics and system-wide economics—caused us to move in that direction." Dr. Berdahl said in diabetic patients the only change to his regimen would be to use a topical NSAID for 3 months. He also said he is not concerned about injecting steroids in glaucoma patients unless they have a known steroid response. Dr. Newsom said his practice used to perform dropless cataract surgery, but ultimately abandoned it (except in certain circumstanc- es) due to issues with higher rates of CME and rebound iritis, which had a significant impact due to the practice's surgical volume. He said rebound iritis in dropless patients was also more severe than that seen in patients who were prescribed drops. continued on page 58 Poll size: 111 In which forms of HSV keratitis have you used topical steroids? Endotheliitis Immune stromal disease Iritis All of the above My typical cataract anti-inflammatory perioperative regimen includes: Preoperative topical NSAID and steroid then postoperative topical NSAID and steroid No preoperative drops and postoperative topical NSAID and steroid only No preoperative drops and postoperative steroid only Intracameral or intravitreal injections only Other

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