Eyeworld

EW CATARACT 68 March 2018 by Maxine Lipner EyeWorld Senior Contributing Writer Pharmaceutical focus injection had a rate of visually sig- nificant CME of zero. The Avastin was not found to be helpful here, he noted. "I think the triamcinolone injection far outweighs any steroid or NSAID in effect," he said. Audrey Talley Rostov, MD, director of cornea, cataract and refractive surgery, Northwest Eye Surgeons, Seattle, includes some drops pre- and postoperatively. Preoperatively, she puts patients on a once-daily NSAID like Prolensa (bromfenac, Bausch + Lomb, Bridge- water, New Jersey) starting the day before surgery and continues them on this for a month postoperatively. "NSAIDs decrease inflammation and decrease the incidence of CME," Dr. Talley Rostov said. "They also help with ocular pain following surgery." She uses a betadine prep in which a drop of betadine is placed in the eye before surgery. She also includes an antibiotic. "I do an intracameral antibiotic injection at the time of surgery," she said, adding that she uses either intracameral cefuroxime or moxi- floxacin depending on whether the patient is allergic to penicillin or ering it from an already small rate to an even smaller rate, so it was a marginal decrease in CME," he said. "If CME does occur, it is readily treatable." Postoperatively, with this regi- men, he finds that there is no need to put patients on any drops. "They have a visible depot for 4–6 weeks, and that's the slowly eluting triam- cinolone," Dr. Shorstein said. Triamcinolone is highly ef- fective against CME, he thinks. Dr. Shorstein cited the Prevention of Macular Edema After Cataract Surgery study in which 213 diabetic patients were randomized into one of four groups. 2 All patients received a steroid and an NSAID drop. The control group received no injection, another group additionally received a 40-milligram subconjunctival triamcinolone injection, the third group received Avastin (bevacizum- ab, Genentech, South San Francis- co), and the final group received triamcinolone plus Avastin. "They found an 8% incidence of visually significant CME in the control group," Dr. Shorstein said, adding that the group that received the drops plus the triamcinolone have shown that the intracameral injection is superior to any drops and that drops don't add anything on top of intracameral injection." Intracamerally, his first line drug is 1,000 milligrams of cefu- roxime, while his second line drug is injecting 0.3–0.4 milliliters of 0.1% moxifloxacin. The approach has been successful for keeping endophthalmitis at bay. "We've had no complications, and we found in Northern California Kaiser Perma- nente that our rate of endophthal- mitis has gone down by about 4- to 5-fold using intracameral," he said. For inflammation and macular edema prophylaxis, Dr. Shorstein subconjunctivally injects triam- cinolone during the procedure. "I have been doing this for 8 or 9 years based on some studies," he said, adding that these showed that the injection of steroid was equivalent to the administration of topical steroid. Dr. Shorstein did his own study that showed a low rate of CME using any prophylaxis regi- men, whether it included NSAIDs or not. 1 "We showed that adding NSAIDs to steroid did lower the rate of CME a little more, but it was low- What platforms cataract practitioners are using W hile all practitioners offer their patients some form of drug coverage around the time of cataract surgery, the approach can vary significantly. For some, the idea is to only deliver medication during the procedure with an injection, while for others such injections are paired with a full complement of drops. EyeWorld asked leading practitioners to share their recommendations. Neal Shorstein, MD, associate chief of quality, Kaiser Permanente, Walnut Creek, California, takes the former approach. He prescribes just a dilating drop for the patient to instill preoperatively on the day of surgery. "Patients instill it in their own eye," he said. "That's the only perioperative drop." Dr. Shorstein doesn't prescribe any antibiotic, NSAID, or steroid drops at this point. "The antibiotic is an intracameral injection at the time of surgery, and that takes care of their prophylaxis for endoph- thalmitis," he said. "Our studies Eyes on the perioperative drug delivery prize Progression of eye in which subconjunctival triamcinolone was used Source: Neal Shorstein, MD

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