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‘Dropless’ cataract surgery enhances prophylaxis, patient satisfaction
Patients are beginning to request this method, which may be the catalyst for more doctors to add it to their repertoire.
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The current topical pharmacotherapy regimen associated with cataract surgery is the most common negative in what is generally a routine procedure.
To help prevent and control infection and inflammation, self-administered ocular drops are often required both before and for several weeks after surgery. The dosing schedule is strict and results in many concerns, the most prevalent being cost and compliance issues. It is safe to say that the one thing most patients hate about cataract surgery is the use of these drops. They are time consuming, inconvenient, expensive and stressful.
These concerns often account for a large majority of time office staff must spend fielding phone calls. The hassle of obtaining the correct medication, with or without insurance, is sometimes unmanageable for patients. Even more concerning, many patients are unable, even if they are willing, to correctly administer the drops or stick to their required schedules. The drops perform well in preventing inflammation and infection, but only if they are used correctly. The unfortunate truth is that the patient is often not getting what they need.
With the development of Imprimis Pharmaceuticals’ (San Diego, Calif.) proprietary compounded drug therapies, Tri-Moxi (triamcinolone acetonide and moxifloxacin HCl) and Tri-Moxi-Vanc (triamcinolone acetonide, moxifloxacin HCl and vancomycin), issues with drops are eliminated. Administering the needed drugs during surgery in a single, injectable, intraocular dose allows the surgeon to pinpoint the best location for the medication, ensuring the patient is receiving exactly what is needed. With drops, even if the patient is diligent in using them, it is very likely they are not receiving their full dosage at the most desired location.
Benefits of going ‘dropless’
My office has comanaged 300 “dropless” surgeries over the past 14 months and we have already seen discernible benefits. There are markedly fewer phone calls from patients or pharmacists pertaining to insurance coverage or cost. The time my office staff spends handling phone calls about drop issues has been dramatically reduced, freeing up time to deal with other matters.
Daniel Schimmel
Even more encouraging are the benefits experienced by patients. They no longer have to be anxious about the drops, whether they had concerns about expenses, the rigorous schedule or the actual application of the drops. For some patients, especially the elderly or physically handicapped, eliminating this concern is invaluable.
Likewise, there is less concern regarding drop compliance. With the needed medication being delivered during surgery in one compounded, injectable application, surgeons can be confident patients have received the medication they need. As the formulation is available to all patients except known steroid responders or those with glaucoma, a good percentage of patients are able to have a greatly improved experience.
Presurgical education, counseling
Patients are educated before surgery on what they may experience after the procedure, especially in regard to photophobia or floaters. In my practice, the majority of patients have not expressed a complaint, with 90% to 95% making no mention of photophobia, and nearly 97% making no mention of floaters. Those who do experience either floaters or photophobia are prepared for the occurrence and, as of yet, have not been upset or concerned by the occurrence.
Despite initial concerns about how patients would respond, we have had no instances where a patient has wished they had opted for the drops over the dropless surgery.
Patients sign a waiver that explains that compounded medications are to be used.
Post procedure
One thing to keep in mind with the dropless surgery is that there may be some activity that is not generally seen with regular cataract surgery. With regular surgery, no cells would be seen in the anterior chamber, but with dropless this is not always the case. There will probably be some medication or cells present; however, this is no cause for concern. The activity will calm down, and by week 2 everything should be quiet.
When performing the dilated exam after surgery, usually a whitish bolus of medication will be seen in the posterior chamber. This is normal and expected.
I employ a traditional cataract surgery postop visit schedule: 1 day, 1 week and 3 to 4 weeks, depending on patient anxiety. I tell patients to call if they have increased pain, increased redness or decreased vision. Patients with any issues will usually come in with complaints of photosensitivity or dull ache. None of my patients have experienced an IOP spike, and I have seen no cases of incision site abscess.
Case example
One of my cases shows how we are still learning what to expect postoperatively. At 1-day postop, the patient’s uncorrected entrance visual acuity was 20/80 with no improvement with pinhole and she had a clear cornea, normal pressure and 4+ anterior chamber reaction. Dilated fundus exam was not possible due to a gray cloudy posterior media. The eye was white, and the patient reported no pain. She was sent home with instructions to call immediately if anything worsened.
Two hours later, the patient called and reported a decrease in vision. She was sent immediately for a retinal consult. The retinologist called to say he was told the patient had a dropped lens. I told him it was dropless cataract surgery. He said there was a lot of inflammation and recommended a vitrectomy the next day with vancomycin.
The formulation is being injected transzonularly during the cataract removal procedure.
Image: Lindstrom RL
The patient did not keep that appointment but rather came to our office. Now 2 days postop, her visual acuity was 20/30, with trace anterior chamber reaction and a clear view of the fundus. I had the patient return the following day when best-corrected acuity further improved to 20/20. The patient proceeded as scheduled for cataract surgery with her second eye, also dropless.
This procedure is so new that even the retinal specialist was not familiar with its postoperative appearance.
Other postoperative expectations
Another way that dropless cataract surgery differs postoperatively is that the “wow” factor may be delayed a bit, but it is certainly not eliminated. If the patient does not experience it on day 1, he or she will probably do so on day 3 or 5. With regard to visual acuity, patients are usually 20/25 to 20/40 day 1 postop.
In the event that a patient has an inflammatory breakthrough, steroids and nonsteroidals may be added postoperatively. Any potential breakthroughs would occur around 1 week, but most eyes are quiet by then. If a patient has inflammation of a 1+ response or greater, we will put him or her on a drop until the inflammation is gone, for possibly up to several weeks. However, the percentage of patients who have breakthrough inflammation and require an additional steroid is very low, generally less than 10%, according to Arbisser and Galvis and colleagues. Regarding concerns of possible endophthalmitis or cystoid macular edema (CME), we have had no cases of the former and only one case of the latter.
Prevention of endophthalmitis may be enhanced because the antibiotics are placed into the vitreous cavity. Prevention or treatment of CME is more effective because the steroid is placed into the vitreous cavity as well. Prevention or treatment of either of these entities is much less successful using conventional topical medications.
As with any new technology, a little refinement of technique is required to master the new procedure. But the benefits of going dropless far outweigh any hesitation. The vast decrease in calls concerning drop issues along with the benefits the patients experience provide ample reason to adopt this procedure. Patients themselves may be the catalyst for more doctors to add dropless cataract surgery to their repertoire, as we have already experienced requests by patients who have heard of the dropless procedure from others.