Eyeworld

EW CATARACT 34 October 2017 Pharmaceutical focus by Maxine Lipner EyeWorld Senior Contributing Writer switch. "We do too many surgeries that are 2 weeks apart," he said. "We weren't willing to risk the bilater- al blindness." Still, Dr. Patterson views using moxifloxacin here as a step down for combating coagulase negative staphylococcus. "There is a higher risk of an infection using moxifloxacin than vancomycin, in my opinion," he said. "MRSA is heavy in my area of the country, and it makes me nervous not having it on board, but I felt like I had to because of the medical legal risk." To help offset the fact that there is no vancomycin in the eye, Dr. Patterson injects a higher 600 mg dose of moxifloxacin intracamerally, which has been shown to have a greater effectiveness against organ- isms. So far patients have tolerated this well. Right after the surgery, Dr. Patterson places one drop each of pilocarpine, betadine, prednisolone acetate, and ketorolac in the eye. No other drops are given that day. "The following day after surgery patients start prednisolone four times a day for 2 weeks and then twice a day until the bottle runs out," he said, stressing that no antibiotics are given and no NSAIDs either. The thinking is that with the intraca- meral approach an antibiotic is not needed. With the intracameral approach, they've had no cases of culture positive endophthalmitis in more than 18 years. As for the postoperative NSAID, after reviewing rates of CME, Dr. Patterson's practice does not view these as necessary. "Our incidence of postoperative CME was no higher without NSAIDs," he said. "We de- cided to forgo them completely. John Berdahl, MD, partner, Vance Thompson Vision, Sioux Falls, South Dakota, uses an intravitreal injection technique that includes dexamethasone, moxifloxacin, and ketorolac. "That formation is nice because the dexamethasone is clear and patients don't have floaters," Dr. Berdahl said. About 75% of his pa- tients use this approach. He likewise prescribes fewer drops to his cataract patients. Beginning 3 days before surgery, he prescribes the LessDrops formulation (Imprimis Pharmaceu- ticals, San Diego), which combines nepafenac, gatifloxacin, and prednis- olone in one bottle. "However, we give the patient the option to get a have a 'wow' effect because of the cloudy media. That led us to switch to a sub-Tenon's injection in 2004. We noted that steroid response was more likely if the triamcinolone injection was more subconjunctival instead of sub-Tenon's. We don't use triamcinolone for anyone who has the slightest hint of glaucoma," Dr. Gills said. In cases where he administers triamcinolone, Dr. Gills finds it to be beneficial in reducing postoperative inflammation, and it eliminates the issue of patient compliance. "I don't have to worry about patient com- pliance, they don't have to take any steroid drops postoperatively, and it's effective," he said. "We're not going to see any CME unless there is some preexisting condition." Postoperatively, patients are placed on Ilevro (nepafenac, Novar- tis) twice a day for 6 weeks and gati- floxacin four times a day for 2 days. For those who do not receive triam- cinolone, Dr. Gills prescribes Du- rezol (difluprednate, Novartis) twice a day for the first 4 weeks. While his regimen includes postoperative an- tibiotic drops for 2 days, his father's protocol did not. "For decades, my father had an exceptionally low rate of endophthalmitis despite the fact that he didn't prescribe antibiotics postoperatively," he said. Michael Patterson, DO, Eye Centers of Tennessee, likewise favors intracameral drug delivery. His reg- imen includes a compounded drop of betadine, ofloxacin and steroid in combination, given to patients in the preoperative area. "For intracam- eral, at the end of every surgery, we inject a combination of moxifloxa- cin and hydrocortisone," Dr. Patter- son said, adding that this is a clear fluid so practitioners don't have to deal with particles in the fluid as they would with triamcinolone. The moxifloxacin is a new addition at this practice, where Dr. Patterson joined his father. "In the last 15 years with my father doing it before me, we did about 16,000 cases with vancomycin, ceftazi- dime, and hydrocortisone, but we switched to moxifloxacin about 6 months ago because of the literature on HORV," Dr. Patterson said. After talking with others including retina colleagues who think there is an association with the vancomycin, Dr. Patterson decided to make the delivered to them," Dr. Yeu said. She is aware that for some, the $40 cost may not be low enough. However, it has been well received in terms of compliance. "Patients love using just one drop," she said. The ketorolac in combination seems to not be as uncomfortable on instillation and hasn't led to the same type of beaten-up epithelium she saw in the past. "We've tested it with about 250 patients," Dr. Yeu said. "It has been going well; it has saved us the call- backs and it's easy for patients." Pit Gills, MD, St. Luke's Cat- aract & Laser Institute, Tarpon Springs, Florida, takes a different approach. He does not typically prescribe drops preoperatively. "In the preop area, we use buffered beta- dine, and our dilating gel contains phenylephrine, mydriacyl, cyclogyl, homatropine, gatifloxacin, brom- fenac, and lidocaine," said Dr. Gills. In the OR, he administers buffered 0.5% betadine—a step Dr. Gills thinks is important in preventing infection. "We give three drops at the beginning of the case and the fourth drop at the end of the case," he said. Dr. Gills' anesthesia regimen includes proparacaine eye drops along with intracameral lidocaine. In the irrigating solution, Dr. Gills includes epinephrine and ascorbic acid in balanced salt solution administered through a 0.22-micron micropore filter. "Years ago, there was a breakout of con- taminated balanced salt solution, so using the micropore filter is one way to reduce that risk," he said. Postop intraocular solutions have changed over the years. "In the early 1990s, my father switched from adding antibiotics to the irrigating solution to an intraca- meral injection of vancomycin, ceftazidime, and dexamethasone. We continued to do that for about 25 years, but in the last year, we changed our intracameral antibiotic regimen to Vigamox [moxifloxacin, Novartis, Basel, Switzerland] due to the concern of retinal hemorrhagic occlusive retinal vasculitis [HORV]," Dr. Gills said. In 2002, they began adminis- tering triamcinolone through the zonules in an effort to reduce the need for postoperative steroid drops. "The transzonular injection of triam- cinolone was very effective in block- ing CME, but the patients didn't T hese days, cataract surgery patients might not have to instill the usual array of drops thanks to new drug delivery practices. Elizabeth Yeu, MD, Virginia Eye Consultants, Norfolk, Virginia, re- cently adopted an intracameral drug delivery approach after studying outcomes with the more traditional use of medications. "We did a deep dive into our results, taking CME as a diagnosis and looking at our last 3,000-plus cases," Dr. Yeu said, add- ing that the number of CME cases was determined to be about 60, with 50% of those occurring while on branded medications. "There was no difference in who developed CME, whether or not we were using branded or generics," Dr. Yeu said. When they considered the fact that two full-time employ- ees were needed for call-backs to patients due to confusion about pre- operative medications, they thought there had to be a better way. This led Dr. Yeu to start thinking about an intracameral drug delivery approach during cataract surgery. "European data, several different studies, plus Kaiser Permanente data show us that intracamerals provide and may be superior to postopera- tive topical medication for endoph- thalmitis prophylaxis," Dr. Yeu said. She decided to begin including this and considered moving to combined compounded preoperative and post- operative medication, which would be less expensive and hopefully improve compliance. Preop, they began using com- bined ketorolac, gatifloxacin, and dexamethasone, Dr. Yeu said. Intraoperatively, they began giving patients intracameral moxifloxacin and dexamethasone. "The dexa- methasone will provide a little bit of an anti-inflammatory jump-start," she said. Postoperatively, she gives patients a compounded combina- tion of gatifloxacin, prednisolone, and ketorolac to be taken four times a day for the first 2 weeks. For the last 3 weeks, patients are given another compounded bottle con- taining only the two anti-inflamma- tories, prednisolone and ketorolac, to be taken four times a day. The approach has proven to be very cost efficient. "Patients are pay- ing $40 to $45 for a full month per eye, and the medications are being The latest cataract surgery drug practices

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