Let it rain: Premium surgeons can remain confident
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One of my favorite phrases of all time is “let it rain,” a proclamation of confidence when the “win” is imminent regardless of the trials that may be faced along the way.
Premium surgeons must always convey a ray of confidence, whether it be in the exam lane preoperatively or postoperatively or in the operating room. Our job takes place in a space of 154 mm3 (anterior chamber volume), and jokingly with my friends on the golf course, I tell them it is 8 mm3, making the golf hole look like the Grand Canyon and that they should be scared.
On a more serious note, despite a perfect premium surgery in such a small space, surgical trauma does occur, and premium surgeons look for ways to maintain that air of confidence with potent options to combat the inflammatory cascade that ultimately follows complex and even routine cataract surgery. From modern-day topical branded steroids and nonsteroidal eye drops to alternative steroid and nonsteroidal drug delivery FDA-approved options, inflammation can be tamed with preserved premium outcomes.
As a class, today’s premium topical steroids and nonsteroidals are typically approved by the FDA for treatment of postoperative inflammation and pain following ocular surgery. But premium surgeons also use these products to help with corneal edema clearance and cystoid macular edema (CME) prophylaxis.
Steroids
Lotemax SM (loteprednol etabonate ophthalmic gel 0.38%, Bausch + Lomb) is submicron strong — or in my opinion, small but mighty — and received FDA approval in February 2019. The SM technology has polycarbophil, which enhances widespread coverage on the ocular surface to maximize absorption potential, and submicron particles, which allow for rapid dissolution with two times greater penetration into the aqueous humor at a lower 0.38% concentration three-times-a-day dosing than its predecessor, Lotemax Gel at 0.5% four-times-a-day dosing. The submicron particles of loteprednol etabonate are 80% smaller as well. Lotemax SM also reaches maximal drug dissolution at 1.5 minutes compared with 5 minutes for Lotemax Gel. The SM formulation is ocular surface-friendly with only 0.003% benzalkonium chloride with a near physiologic pH of 6.5, a must-need for premium IOL patients.
Inveltys (loteprednol etabonate ophthalmic suspension 1%, Kala Pharmaceuticals) uses Ampplify drug delivery technology for twice-daily dosing through mucus-penetrating nanoparticles to reach target tissue concentrations in the cornea to alleviate pain and aqueous humor to mediate inflammation resolution. It has an excellent safety profile with minimal to no clinically significant side effects.
My last go-to topical steroid in premium cataract surgery is Flarex (fluorometholone acetate ophthalmic suspension 0.1%, Eyevance Pharmaceuticals) as it has the potency of a ketone steroid but the safety profile of fluorometholone in terms of IOP protection. Flarex is a fluorometholone acetate vs. the alcohol that is in FML (fluorometholone, Allergan). The acetate derivative improves lipophilicity, providing better penetration, but it is a steroid ester providing IOP safety. Flarex was found to be more effective than FML alcohol suspension in curing ocular surface inflammation, 68% vs. 43% within 13 days of treatment onset, another important advantage in premium IOL surgery.
Alternative choices
Alternative drug delivery options have also been advantageous, especially for those patients who are noncompliant and/or have poor ocular surface issues to begin with preoperatively.
Dexycu (dexamethasone intraocular suspension 9%, EyePoint Pharmaceuticals) is the first and only FDA-approved single-dose intracameral steroid for postoperative inflammation. It is delivered as a 2-mm spherule with Verisome technology, providing a relatively high initial dose of steroid that decreases over a 30-day period in most patients. Three times more Dexycu patients had complete anterior chamber cell clearance at day 8 compared with placebo. The newer subcapsular technique allows for more reproducible placement of the drug behind the iris and out of the anterior chamber. My preference for this product is in denser cataracts with more inflammation postop due to higher phacoemulsification times intraoperatively.
Dextenza (Ocular Therapeutix) is dexamethasone in an intracanalicular insert delivered over 30 days from the punctal area for the treatment of ocular inflammation and pain following ophthalmic surgery. I use the “5D” approach to placement: drag the lid temporally, dry the puncta area, dilate the punctum, direct the insert horizontally to bypass the initial 2-mm turn into the canaliculus, and don’t be dumb (know the anatomy well).
Lastly, Omidria (phenylephrine 1% and ketorolac 0.3% intraocular solution, Omeros) is the first and only FDA-approved NSAID-containing product for intraocular use to maintain pupil size by preventing intraoperative miosis and to reduce postoperative ocular pain. Real-world experience and studies have shown Omidria to reduce CME and breakthrough iritis, decrease the use of pupil-expanding devices, reduce the need for perioperative opioids and prevent intraoperative floppy iris syndrome-related complications. Omidria has the advantage of containing both ketorolac and phenylephrine.
In summary, premium cataract surgery can come with lots of good and unexpected surprises, but premium surgeons can remain confident despite the rain with so many anti-inflammatory options to combat the storm that can follow.
Stay healthy and let it rain, even in COVID times.
- References:
- Cavet ME, et al. J Ocul Pharmacol Ther. 2019;doi:10.1089/jop.2018.0136.
- Dembski M, et al. J Clin Med. 2021;doi:10.3390/jcm10051094.
- Donnenfeld ED, et al. Clin Ophthalmol. 2019;doi:10.2147/OPTH.S229515.
- Fong R, et al. Clin Ophthalmol. 2019;doi:10.2147/OPTH.S210597.
- Leibowitz HM, et al. Ann Ophthalmol. 1984;16(12):1110-1115.
- Silverstein SM, et al. J Cataract Refract Surg. 2018;doi:10.1016/j.jcrs.2018.05.029.
- Visco D. Clin Ophthalmol. 2018;doi:10.2147/OPTH.S149522.
- Walter K, et al. J Cataract Refract Surg. 2019;doi:10.1016/j.jcrs.2018.11.004.
- 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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