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Modified dropless cataract surgery can improve postsurgical results
One practice also adds a nonsteroidal anti-inflammatory for even better outcomes.
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In the months since implementing dropless cataract surgery, the patients and physicians in our practice have enjoyed considerable advantages to this approach.
Using the Tri-Moxi injectable formulation (triamcinolone acetonide and moxifloxacin HCl, Imprimis Pharmaceuticals) typically eliminates the need for pre- and postoperative administration of topical medication. As multiple drops usually need to be administered several times per day, removing this inconvenience creates a much more pleasant overall experience for patients.
Improved compliance, reduced cost
We have also experienced a considerable decrease in the number of telephone calls from the pharmacy to our office, freeing our staff to better utilize their time and skills elsewhere. These calls most often regarded drop substitution, primarily due to cost or insurance denial of medication. Resolving the cost issue is a significant benefit as drops can reach up to $650 per eye for the patient (Chang, et al.). The savings will number in the billions of dollars over the next decade for both insurance companies and patients by eliminating or greatly reducing necessary drops.
Additionally, with the traditional drop regimen, many patients struggle with compliance and do not receive full doses of the medications they need. An intraocular injection provides the assurance that the patient is receiving the appropriate dosage of the correct medication needed for optimum postsurgical results.
Currently, we are offering dropless surgery only to those patients who choose premium lenses. Insurance does not cover the use of Tri-Moxi, but there is no direct out-of-pocket expense for the patient for this approach.
We do not use this technology for patients with diabetes or glaucoma or those in whom we suspect glaucoma. Despite some early setbacks, both patients and surgeons have found the results favorable.
Chart review
To thoroughly understand if using Tri-Moxi was a benefit to our patients, we felt we needed to know precisely what percentage of patients were having breakthrough inflammation so that we could analyze what is an acceptable or expected percentage of breakthrough and if the steroid we were using was effective. In an attempt to uncover the answers to these questions, a chart review was initiated.
One hundred seventeen consecutive dropless cataract surgeries were reviewed. These patients were evaluated on day 1, at week 1 and at month, 1 with additional appointments as necessary. Normal postoperative examinations were completed at each visit. If the patient appeared for an unscheduled appointment with complaints related to inflammation, it was the examining doctor’s choice whether to begin treatment with topical steroid drops. This event was entered as an intervention for inflammatory breakthrough.
Prior to beginning the chart review we contacted practices who had been performing dropless cataract surgery. These practices reported an average of 10% breakthrough inflammation following dropless cataract surgery. Our current rate of breakthrough is 8.2%, a fairly reasonable and acceptable rate. However, we decided to avoid even this low rate of inflammation by providing all Tri-Moxi patients with a nonsteroidal anti-inflammatory to be used once a day until the bottle is empty. We use either Ilevro (nepafenac ophthalmic suspension 0.3%, Alcon) or Prolensa (bromfenac ophthalmic solution 0.07%, Bausch + Lomb). This has virtually eliminated inflammation issues. It should be noted that if a patient receives an arcuate incision to manage astigmatism, he or she is also given an additional antibiotic drop for 3 days post-surgery.
Atypical IOP spikes are rarely seen. Depending on the degree of IOP elevation, treatment choices include an alpha agonist, beta-blocker, a combination of the two, combination brinzolamide and brimonidine, or an oral carbonic anhydrase inhibitor.
Patients also rarely experience ocular surface symptoms at the site of the clear corneal incision. If they do, however, we would recommend the use of Systane Balance (Alcon) or Soothe XP (Bausch + Lomb).
Dropless cataract surgery with intraoperative administration of Tri-Moxi is safe and successful in the control of postoperative cataract inflammation and for the prevention of endophthalmitis. The elimination of concerns such as cost, convenience and compliance leads to a significantly improved overall experience for both patients and physicians.
- References:
- An JA, et al. J Cataract Refract Surg. 2014;40(11):1857-1861. doi: 10.1016/j.jcrs.2014.02.037.
- Andrew Chang and Co. Analysis of the economic impacts of dropless cataract therapy on Medicare, Medicaid, state governments and patient costs. October 2015. Accessed September 2, 2016. http://www.improvedeyecare.org/CSIE_Dropless_Economic_Study.pdf.
- Schwartz GF, et al. Curr Med Res Opin. 2013;29(11):1515-1522. doi: 10.1185/03007995.2013.833898.
- Stone JL, et al. Arch Ophthalmol. 2009;127(6):732-736. doi: 10.1001/archophthalmol.2009.96.
- For more information:
- Daniel Schimmel, OD, practices at Loden Vision Centers in Nashville. Since 1987, he has been involved in both administrative and direct clinical care of clients at large referral centers in Knoxville, Tenn., Nashville and Chicago. He can be reached at dnlschimmel@yahoo.com.
Disclosure: Schimmel reports no relevant financial disclosures.