The COVID compliance factor: Are our premium patients really compliant?
Alternative drug therapies can mean less reliance on patient cooperation in the postoperative period.
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So, as the COVID pandemic has that false appearance of ending soon with more nonessential businesses opening and finally essential eye businesses opening and starting to operate again on the precious item called “sight,” the word “compliance” takes on several new meanings and definitions simultaneously.
The Webster dictionary defines compliance as the act of or process of complying to a desire, demand, proposal or regimen. With the COVID pandemic easing, new compliance factors come with staying at home, social distancing, and wearing masks or facial coverings in public places. However, pandemic compliance has had many flaws no different from our own patients’ compliance when it comes to adhering to postoperative regimens and restrictions, especially after premium cataract surgery. Wearing masks has brought an array of incomprehensible nonadherence that risks spreading the coronavirus in possibly an even more dangerous way than ever. Wearing a mask only over the mouth and not the nose has no protection whatsoever, touching your mouth to wet your finger tips under a mask to open a grocery bag is dangerous, and not wearing a facial covering is just simple noncompliance or lack of self-worth at this stage of the pandemic.
Focusing on what we do as premium surgeons is not much different. Premium surgeons can do perfect cataract or refractive surgery, but patients can be, intentionally or unintentionally, noncompliant in the perioperative/postoperative period, which typically brings poor outcomes and adverse events, leading to frivolous lawsuits and/or reduced word-of-mouth referrals. Remember, premium surgeons are most likely responsible for 80% of the outcome, but the remaining 20% relies on patient adherence and compliance. Many studies have shown postoperative regimens consisting of mostly eye drops can be cost inconvenient for some patients. Other patients may simply forget to put in their drops, some may remember but instill them improperly, and some compliant patients may experience unwanted side effects such as ocular surface toxicity. Most patients have self-administration issues such as missing their eye completely, contaminating the bottle tip or touching the tip to their corneal surface, causing an epithelial defect and leading to unwanted postoperative corneal astigmatism and/or recurrent erosions.
Many premium surgeons use alternative drug therapies to substitute topical steroid use such as Dextenza (dexamethasone ophthalmic insert 0.4 mg, Ocular Therapeutix) as an intracanalicular steroid insert or Dexycu (dexamethasone intraocular suspension 9%, EyePoint Pharmaceuticals) as an intracameral delayed-release Verisome spherule. Omidria (Omeros) is an intraoperative continuous irrigation intracameral solution of ketorolac and phenylephrine to help guard against pupil miosis intraoperatively and pain postoperatively, but recent research has shown a benefit of reduced pseudophakic cystoid macular edema when used with postoperative once-daily topical NSAIDs alone such as BromSite (bromfenac ophthalmic solution 0.075%, Sun Pharmaceutical) or Prolensa (bromfenac ophthalmic solution 0.07%, Bausch + Lomb) without steroids.
Adding an intracameral antibiotic such as moxifloxacin or cefuroxime could potentially eliminate any need for patient compliance ultimately. These alternatives still have their issues and potential adverse events themselves, and as such there is no perfect regimen. We have great nanotechnology steroids such as Inveltys (loteprednol etabonate ophthalmic suspension 1%, Kala Pharmaceuticals), which uses Ampplify technology to enhance absorption through the cornea, and submicron particle drops such as Lotemax SM (loteprednol etabonate ophthalmic gel 0.38%, Bausch + Lomb), with twice the aqueous penetration with the aid of its mucoadhesive polycarbophil polymer. These options are still viable and rely less on patient compliance in terms of frequency of use and better efficacy.
Despite our current COVID pandemic and poor real-world compliance with overcrowding beaches, lack of personal protective equipment and inadequate handwashing/sanitizing gel usage, businesses are at least resuming with hope for a reviving economy sooner than later, and premium surgeons are getting back to doing essential eye sight restoration. Compliance will never really change, even in the face of a pandemic, but our evolving ophthalmic perioperative regimens will rely less on patient compliance and hopefully supersede the tragedy of our current crisis. Stay strong, stay safe to all my premium surgeons.
- Reference:
- Walter K, et al. J Cataract Refract Surg. 2020;doi:10.1097/j.jcrs.0000000000000062.
- For more information:
- Mitchell A. Jackson, MD, can be reached at Jacksoneye, 300 N. Milwaukee Ave., Suite L, Lake Villa, IL 60046; email: mjlaserdoc@msn.com.
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