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Dropless cataract surgery offers cheaper price but possible disadvantages
NEW ORLEANS — Dropless cataract surgery is cheaper for the patient and the health care system, but compounding issues and adverse events may be problematic, according to a speaker here.
“Are these downsides to dropless surgery worth it? There are compounding issues, clearly. Triamcinolone has crystals, so they can cause floaters. Will you damage the zonules? Will it cause intraocular pressure spikes? Triamcinolone has been associated with intraocular pressure spikes. Infectious disease doctors always make me feel bad about using these medications because they’re always worried about antibiotic resistance,” Mitul C. Mehta, MD, said at the American Academy of Ophthalmology meeting.
However, the cost of the drugs for the patient and the health care system is as low as $17 from a compounding pharmacy compared with a more expensive bottle of branded antibiotics. Dropless cataract surgery takes drop compliance out of the equation as well, Mehta said.
There is also the claim that dropless cataract surgery results in less cystoid macular edema, but this has not been proven yet, he said.
A parallel exists between dropless cataract surgery and previous bevacizumab compounding issues, but bevacizumab use is still prevalent and much better with current compounding pharmacy practices, Mehta said.
“The question is, do we need more government regulation? I’m not sure about that. I think the government needs to step up and do what they’re supposed to do on these regulations with these pharmacies. We need to be vigilant ourselves as physicians as to who we’re choosing to get our medications from,” he said. – by Robert Linnehan
Reference:
Mehta MC. Dropless cataract and its impact on retina. Presented at American Academy of Ophthalmology annual meeting; Nov. 11-14, 2017; New Orleans.
Disclosure: Mehta reports no relevant financial disclosures.
Perspective
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Dr. Mehta makes some important points in his presentation on dropless cataract surgery.
First are the concerns about where the medications come from. At present, Imprimis Pharmaceuticals is one of the few companies that has 503A FDA certification allowing shipping of its sterile compounded product in all 50 states. Local or state-based pharmacies cannot do this and do not have the same oversight. No matter who prepares the drug that you will inject into a patient’s eye, you must be comfortable with the reputation of that compounding pharmacy as errors in drug preparation have occurred and will most likely occur in the future. Now the advantages of performing dropless surgery can be great both for surgeon and patient. Intravitreal injections of triamcinolone/moxifloxacin can save the patient from using any drops in many cases and the surgeon can be assured that the patient received the medication. No wondering whether the patient really used it when persistent inflammation or infection occurs. The savings to our beleaguered health systems could be tremendous if more physicians and patients requested these medications. Imagine, close to no prescription costs for the No. 1 elective surgery performed in the United States. Breakthrough inflammation creating the need for drops can occur but is rare in my experience.
Less drops can be a useful alternative as well. Simply instilling the medication (combo or just triamcinolone) in the anterior chamber at the end of the case can give a potent amount of anti-inflammatory effect for patients with a history of uveitis, vitreous loss, or who are just more susceptible to inflammation.
I agree with Dr. Mehta in that more government intervention with compounding pharmacies is not desirable and could possibly restrict the availability of very important medications that surgeons wish to use. Rather, physicians need to insist on the best pharmacy practices and report anything that is not consistent with these practices.