Cornea panel addresses challenging cases at OSN New York
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At OSN New York 2023, Eric D. Donnenfeld, MD, and a panel of corneal experts assembled to discuss hot topics such as NSAID use after cataract surgery and dropless regimens.
In this issue of Healio | OSN, Donnenfeld and colleagues tackle complex and interesting corneal cases from the meeting stage, including Loa loa and cataract in a patient with diabetes.
Eric D. Donnenfeld, MD: This is a bit of a bread-and-butter case, something that you see every day in your practice. You may change the way you manage these patients after this discussion. This is a 78-year-old male physician with a chief complaint of decreased visual acuity (Figure 1). There is nothing special about it — he has a cataract. He has diabetes and is on oral medications. He has had diabetes for 15 years. He has a little cataract, a little background retinopathy and no cystoid macular edema (CME). His OCT looks perfectly normal, and he requests cataract surgery.
When would you start topical NSAIDs on this patient prior to cataract surgery? The FDA says you start 1 day preoperatively. Would you start 1 week prior to surgery, 3 days, 1 day, the day of surgery, or do you say, “I don’t use NSAIDs on this patient?” Dr. Hovanesian, how do you feel about not using an NSAID on a physician with diabetes having cataract surgery?
John A. Hovanesian, MD, FACS: As with all patients, we want the best outcome we can obtain, and NSAIDs certainly are linked to less risk for macular edema, and it is particularly a higher risk among patients with diabetes. Although I know it is pretty common to not use an NSAID, I would use one.
Donnenfeld: Dr. Nattis, how long would you use NSAIDs postoperatively?
Alanna Nattis, DO: I would do at least 4 weeks.
Donnenfeld: I opt for 4 weeks on my routine cataract surgery. For a patient with diabetes, I usually go to 8 weeks or so. I think a minimum of 8 weeks is good in that patient group.
The ESCRS PREMED study from 2018 was an extraordinarily well-done study on NSAIDs and steroids in routine patients having cataract surgery, with around 1,000 patients evaluated. The researchers gave some patients steroids, some patients NSAIDs and some patients both.
If you had to choose, which one do you think would be more important, the NSAID or the steroid? The NSAID was actually more effective than the steroid, but the combination of both was preferable to all three of them.
The second part of that same study is probably the study that has influenced my management of patients with diabetes more than anything else. This one looked at patients with diabetes only. The authors found that patients with diabetes who underwent cataract surgery and received 40 mg of triamcinolone had significantly less macular edema than patients who received anti-VEGF therapy. So, of all the things that you could do for patients having cataract surgery, administering a triamcinolone injection was the best thing.
Do any of you do this? What do you think of this method?
P. Dee Stephenson, MD, FACS: I do it, but I also get the retina doctor involved from day 1. A lot of the time they will administer anti-VEGF before surgery or 2 weeks after, and they are following the patient closely. So, if the patient has CME, we try to prevent it. We also tell them that they are at high risk.
Donnenfeld: It is useful to educate our retina colleagues about managing maculopathy. Some of them are not aware of the important things that we know.
Nicole R. Fram, MD: I routinely perform complex surgery, and I always administer triamcinolone or dexamethasone at the end of the case. About 7 years ago, I asked myself, “Why am I not doing this for patients with diabetes or high-risk people for CME?” I think it makes sense.
Donnenfeld: In patients who are diabetic, you will get a pressure spike occasionally. That is one thing you have to worry about.
Which patient group is most likely to get a pressure spike after cataract surgery?
Fram: Young patients and those who receive sub-Tenon’s anesthesia.
Donnenfeld: Exactly, young patients and high myopes. Those are the ones you want to be concerned about, anyone who is over about –8 D.
Fram: Is that because the sclera is so thin?
Donnenfeld: It is probably due to lack of rigidity in the trabecular meshwork. David F. Chang, MD, wrote the definitive paper on this a number of years ago. The paper showed that patients who were over –10 D had a 20 times greater rate of having pressure rise.
Nonsteroidal and dropless regimens
Donnenfeld: This is another interesting case. We have an 80-year-old woman with rheumatoid arthritis who cannot take drops and cannot squeeze the bottle (Figure 2). The family is unavailable to give medications to this patient. How would you manage the pharmaceuticals?
Hovanesian: Thankfully, today we have a number of tools that are not eye drops to help us give the required medication. I think that the data on antibiotics for intracameral dosing are compelling, and it is what many of us have already moved to in our practices.
As far as a steroid, we have FDA-approved solutions such as dexamethasone that can be delivered either in the canaliculus or intracamerally and give a full dose of steroid postoperatively. That leaves the nonsteroidal options. Drops are generally once a day for the branded products, which is fairly safe and doable. Even for patients who are compromised, that works. However, it may not be necessary if you use Omidria (phenylephrine 1% and ketorolac 0.3% intraocular solution, Rayner) at the time of surgery because you are getting at least a few days of nonsteroidal dosing that is retained inside the eye after surgery.
Donnenfeld: We have a lot of options right now. You can use subconjunctival triamcinolone, and if the patient qualifies, we can use Dextenza (dexamethasone ophthalmic insert 0.4 mg, Ocular Therapeutix). We have stopped Dexycu (dexamethasone intraocular suspension 9%, EyePoint Pharmaceuticals) in our practice, but Dextenza is a viable alternative.
Most of us use fluoroquinolones. In Europe, they do not use fluoroquinolones or antibiotics at all anymore after cataract surgery. They administer intracameral medication and nothing topically. There is some literature to support the idea that we may not have to use the antibiotic postoperatively, so I don’t really worry about the antibiotic.
I worry about the steroid and try to give nonsteroidals. Dr. Hovanesian mentioned the use of Omidria, which has intracameral ketorolac. In addition to keeping the pupil dilated, I think it gives you significant prophylaxis against CME.
A study showed 31% of patients without previous eye drop experience cannot take their eye drops effectively. Every now and then, I will ask my patients to put drops in and video them.
Fram: I think it depends on how dark the irides are. You have to pay attention to who in your patient population may have some rebound inflammation. So, I will supplement. I will use Dextenza, I will use my dropless protocol, but I will also supplement with triamcinolone subconjunctivally.
Donnenfeld: The old belt and suspenders technique.
Dr. Hovanesian, would you like to discuss your published paper on intracameral dexamethasone 9% vs. prednisolone acetate 1% for controlling postoperative pain and inflammation?
Hovanesian: In 30 patients, in one eye we gave a dropless regimen and in the other eye a regimen of the usual three-drop cocktail postoperatively. We looked at outcomes of surgery in terms of signs of inflammation, pain and risks of rebound inflammation and followed them for a month. We also, most importantly, asked the patients, “What’s your preference?” Not surprisingly, the preference was overwhelmingly in favor of the dropless regimen. It is important to note we randomized which eye was first. We were pleased to see that summed ocular inflammation scores were essentially similar following surgery.
Donnenfeld: Dr. Hovanesian and I followed that analysis up with a follow-up study looking at Dextenza. We found no significant difference with using intracameral ketorolac, moxifloxacin and dexamethasone inserts vs. using the standard drop therapy.
I think there is still a good future for punctal plug dry delivery. We published a study in the Journal of Cataract & Refractive Surgery a couple of years ago that showed patients had no pain overwhelmingly when given the NSAID, which you would expect vs. a control. There was less inflammation, as you would expect. What was amazing was that when patients were given a steady state of low levels of nonsteroidal, they had better vision in a statistically significant way. I don’t know how I can exactly explain why that is, but this was overwhelming. This is an FDA trial. This is something that is written in stone and is an accurate trial. The vision was better with a steady state of nonsteroidal that was given in the surgery.
This is my dropless surgery today. You get Omidria in the bottle and moxifloxacin at the end of the case. I will then give a subconjunctival injection of triamcinolone. I don’t use 40 mg for most patients. Instead, I will usually use 20 mg because 40 mg is a fairly large volume. Then, if I want the belt and suspenders technique described by Dr. Fram, I will actually take out the speculum. I don’t know why more people don’t use intracanalicular dexamethasone. You dilate the punctum. I take viscoelastic, put it on the plug, and that helps you slip in more easily. Now you have a steady state of steroid. Not only is this going to be good for intraocular inflammation, but it is the best ocular surface management you can possibly have.
This treats dry eye better than anything. You are getting a steady state of low-level non-preserved steroids, so your ocular surfaces are pristine. If you are interested, try it. I think it is a nice thing to add to your surgery.
Fram: Ask your patients if they have ever had a smart plug. If they are dissolvable plugs and you irrigate beforehand, that is OK. But if they have had a smart plug and then you put this in, you can lodge it and cause a lot of epiphora for a long time. That question is part of our patient questionnaire now.
Cost is also a factor. Why isn’t everybody doing it? It is an issue of cost. The company has done a great job in working with the surgery centers so that it is a pass-through, and then there is a rebate. I know people get into discussions about, “As these drugs come to market, why are we spending so much for these drugs?” But there is a special area that deals with new drug development where that money is coming from, so it is not necessarily coming out of your pocket. I have done a lot of research in this area. I think if you have a good relationship with these people, you can have innovative ways to deliver dropless technology.
Hovanesian: When you have had some experience with these products, you are not surprised to see the trial results that show better visual acuity and less pain. You realize that drops are so unfriendly to the eye. If we had these sustained-delivery therapeutics as standard of care and then eye drops came along as an alternative, nobody would use the eye drops.
Stephenson: Something I do in really dense cataracts is give them a Solu-Medrol (Pfizer) 100 mg IV push.
A case of Loa loa
Donnenfeld: A 21-year-old college soccer player came in with a red foreign body sensation in the eye (Figure 3). The patient said, “I feel something crawling under my eye.”
Source: Eric D. Donnenfeld, MD
Hovanesian: It is Loa loa.
Donnenfeld: Yes, this is a classic case of Loa loa. This is a systemic disease and needs to be treated systemically. In this case, I decided that I wanted to remove it. You do not want to leave the parasite there on the eye. I put the patient under an operating microscope with topical anesthetic applied and used a Q-tip to try and grab the parasite. Each time I tried to remove the parasite, it would crawl into the cul-de-sac, and I could not find it. For about 15 minutes, this Loa loa outsmarted me in the office. Eventually, I took a cocaine pledget and put it on top of the Loa loa. I then made an incision and pulled the Loa loa out.
Fram: How did you know you got it all?
Donnenfeld: The ends are very rounded. It is round, but the ends are tapered. The patient was happy to have it gone.
- References:
- An JA, et al. J Cataract Refract Surg. 2014;doi:10.1016/j.jcrs.2014.02.037.
- Donnenfeld ED, et al. Clin Ophthalmol. 2023;doi:10.2147/OPTH.S422502.
- Donnenfeld ED, et al. J Cataract Refract Surg. 2021;doi:10.1097/j.jcrs.0000000000000414.
- Hovanesian JA, et al. J Cataract Refract Surg. 2022;doi:10.1097/j.jcrs.0000000000000887.
- Wielders LHP, et al. J Cataract Refract Surg. 2018;doi:10.1016/j.jcrs.2018.01.029.
- Wielders LHP, et al. J Cataract Refract Surg. 2018;doi:10.1016/j.jcrs.2018.05.015.
- For more information:
- Eric D. Donnenfeld, MD, of Ophthalmic Consultants of Long Island, can be reached at ericdonnenfeld@gmail.com.
- Nicole R. Fram, MD, of Advanced Vision Care in Los Angeles, can be reached at drfram@avceye.com.
- John A. Hovanesian, MD, FACS, of Harvard Eye Associates in Laguna Hills, California, can be reached at jhovanesian@harvardeye.com.
- Alanna Nattis, DO, of SightMD New York in Babylon, New York, can be reached at asn516lu@gmail.com.
- P. Dee Stephenson, MD, FACS, of Stephenson Eye Associates in Venice, Florida, can be reached at eyedrdee@aol.com.
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