Surgeon shares how compounding has taken on large role in his cataract surgery practice
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At Williamson Eye, we have converted to compounded intraoperative and postoperative medications for all our cataract surgery procedures. We also use compounded drugs for postoperative LASIK drops and some other indications.
We find that these medications are convenient and cost-effective for patients and reduce the workload on staff.
Benefits for patients
All our cataract patients get a three-in-one intracameral injection of Dex-Moxi-Ketor (dexamethasone 1 mg/mL, moxifloxacin 0.5 mg/mL, ketorolac 0.4 mg/mL, ImprimisRx) at the conclusion of surgery. Studies have shown that intracameral antibiotics significantly reduce the risk for endophthalmitis compared with topical antibiotics alone. Since instituting this regimen a couple years ago, endophthalmitis has become virtually nonexistent, which is encouraging.
We then send patients home with a compounded triple drop of Pred-Moxi-Nepaf (prednisolone acetate 1%, moxifloxacin 0.5%, nepafenac 0.1%, ImprimisRx) to be used twice daily for 3 weeks in each eye.
This approach checks so many boxes for patients. First, through the 503B outsourcing program, we are able to order the drops in bulk and dispense them from the practice, so our patients do not have to waste any time filling prescriptions at a pharmacy or waiting for out-of-stock drops to be ordered. From a lifestyle perspective, that is convenient. Patients scheduled for advanced IOL implantation receive the drops from us as part of their postoperative care package at no additional cost. This streamlines their experience and prevents them from feeling “nickeled and dimed” after paying out of pocket for the advanced IOLs.
I believe there are significant compliance benefits from reducing the number of bottles and the complexity of the regimen for patients. Instead of having three different bottles and three different dosing schedules that add up to nine to 12 drops throughout the day, they can use one easy-to-remember bottle. The bottle has approximately 140 drops in it, which is sufficient for both eyes. Depending on their particular insurance and formulary benefits, this approach may save patients hundreds of dollars in medication co-pays.
From my perspective, I do not have to worry that a patient got the wrong drops from the pharmacy, neglected to fill the prescriptions or got confused about which drops to use.
Benefits for practice
One of the biggest benefits for our practice, however, has been the reduction in staff time to deal with pharmacy callbacks. For a typical surgical day, we would take calls from the pharmacy and/or the patient in about 60% of cases, with each call taking 5 to 10 minutes of staff time to confirm prescriptions, approve alternatives, address cost issues or deal with ordering delays. We estimate that eliminating these calls has saved us 250 to 500 hours of staff time per year.
Safety considerations
As discussed above, intracameral antibiotics reduce the risk for endophthalmitis, but there is no question that surgeons also need to take the utmost care in choosing a compounding pharmacy for injected medications. It is important to mitigate risk by asking questions about suppliers’ quality standards and track records. Before I began using compounded intracameral drugs, for example, I wanted to know how long the pharmacy had been in operation, whether it was an FDA-registered and -inspected laboratory, and whether it had ever had any cases of toxic anterior segment syndrome, retinal vasculitis or infection.
Surgeons might also consider asking whether every batch of a formulation is tested for potency, sterility and endotoxins; how often the facility conducts environmental monitoring; and whether it participates in the MedWatch adverse event reporting program. These are all requirements of 503B outsourcing facilities (Table 1), which typically follow the same high manufacturing standards as commercial pharmaceutical companies, so doctors can feel confident in the reliability and quality of the medications obtained from these facilities.
Source: Blake K. Williamson, MD, MPH, MS
Compounding has enabled us to simplify drop regimens for patients and improve convenience and compliance in cataract surgery and beyond. With now well-established safety records, it is definitely something worth considering for busy practices.
- References:
- Endophthalmitis Study Group, et al. J Cataract Refract Surg. 2007;doi:10.1016/j.jcrs.2007.02.032.
- Shorstein NH, et al. J Cataract Refract Surg. 2013;doi:10.1016/j.jcrs.2012.07.031.
- For more information:
- Blake K. Williamson, MD, MPH, MS, can be reached at Williamson Eye, 550 Connell’s Park Lane, Baton Rouge, LA 70806; email: blakewilliamson@weceye.com.
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