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Post-cataract surgery intraocular injections offer alternative to traditional drop therapy
Injections of Tri-Moxi-Vanc can benefit patients, surgeons and staff.
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With more than 3 million procedures performed annually in the U.S., cataract surgery is nearly a rite of passage. Technological advances including phacoemulsification and premium IOLs have all contributed to making cataract surgery one of the safest and most effective procedures performed. However, the post-surgical drop regimen has remained a largely unchanged and cumbersome process for both patients and office staff.
As an “in the trenches” surgeon working to provide the best care for my patients, I believe the time has arrived to confidently adopt the practice of administering post-surgical pharmacological treatment intraocularly. Patients benefit from the convenience and affordability, and my staff is relieved of many of the calls we receive from patients and pharmacies. To best serve the needs of my patients, I adopted Tri-Moxi-Vanc therapy (Imprimis Pharmaceuticals) into my surgical armamentarium. The compounded medication consists of a proprietary formulation of triamcinolone acetonide, moxifloxacin hydrochloride and vancomycin in a sterile package. The product is ordered from an accredited compounding pharmacy and delivered directly to the office.
In recent years, the cost of prescription drops has risen tremendously. The large variation in formularies coupled with the differentiation in what each pharmacy stocks makes ensuring my patients receive a quality drug at an affordable price difficult. Furthermore, many patients hate and even fear drops. The majority of cataract patients are elderly, and many have ailments such as arthritis or tremors, and may even require a caregiver to instill the drops. Keeping track of the drops is often a frustrating and daunting prospect for patients. As a surgeon, I worry that having my patient bring an object close to the eye multiple times a day will result in trauma if the eye is bumped.
Patient choice
When counseling patients, we involve them in the decision-making process. With both our traditional and advanced implant patients, we initially determine what sort of visual outcome they want: Do they want traditional cataract surgery and more use of spectacles, or do they want refractive cataract surgery and less dependence on glasses? Once we figure out the desired outcome, we then educate them on the traditional drop method and the injection method and allow them to decide whether they prefer to administer their own drops or have them administered intraocularly at the time of surgery.
The majority of patients have heard about the challenge and volume of drops from their friends, and this is one of the biggest concerns they express. Patients overwhelmingly choose the injectable therapy despite the possibility that they may experience peripheral floaters, visible over a 2- to 4-day time period, that dissipate as the drug is reabsorbed. Patients are not deterred by the prospect of floaters, and acceptance of this possibility is high. We have found that this effect is less dramatic than we thought it would be; however, it is important to tell patients because it is prevalent enough to be unsettling if we did not prepare them. We do not offer the injectable option to patients who present with elevated IOP in case they experience a steroid response. We also do not routinely offer it in patients who have had a vitrectomy.
I also emphasize that patients will not be completely drop-free because nonsteroidal medications cannot be administered via injection; as such, I still prescribe a nonsteroidal once a day to reduce inflammation and promote a quieter eye. The nonsteroidal is also used to reduce the chances of cystoid macular edema and has been proven over the years to be beneficial in protecting the retina. We refer to the injectable drop method as our “drop a day” program. Typically, traditional cataract patients take three drops: antibiotic, steroid and nonsteroidal. With the injection method, patients take only the nonsteroidal once a day.
Learning curve
Initially I had some trepidation about injecting the solution directly into the vitreous. The success reported by physicians who inject through the zonules as well as those who inject via the pars plana (measuring 3.5 mm posterior to the posterior limbus) provided adequate reassurance. After considering the high number of injections that occur through the pars plana in many office procedure rooms for macular degeneration across the country, I opted to proceed with the pars plana approach. I quickly navigated the learning curve, and the positive feedback from my patients as well as my colleagues further reinforced my conviction to offer this option.
Financial considerations
The primary negative is the inability to bill for the product and recoup the cost. However, I have built my career on answering patients’ needs, and if I do a good job for patients, even if I have to absorb a portion of the cost, I know they will tell their friends that they can trust me, and that helps grow our practice. Intraocular drug administration is simply good for our practice’s health because the patients love it. It saves them money and hassle.
Conclusion
Compounded medications make sense. Creating a depot of medication in the vitreous and having it be at the same site that we inject if there is an infection is comforting as a surgeon. I know that when my patient leaves the surgical center, I do not need to worry because the antibiotic and steroid protection is on board and is not patient dependent.
- References:
- Cataract statistics. Statistic Brain Research Institute website. http://www.statisticbrain.com/cataract-statistics/. Updated July 28, 2013. Accessed May 7, 2015.
- Kessel L, et al. Ophthalmology. 2014;doi:10.1016/j.ophtha.2014.04.035.
- For more information:
- Vance Thompson, MD, can be reached at Vance Thompson Vision, 3101 W. 57th St., Sioux Falls, SD 57108; email: vance.thompson@vancethompsonvision.com.
Disclosure: Thompson reports he is a consultant with Imprimis.