Advances in therapeutics simplify postop inflammation management
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Consistent and comprehensive communication between optometrists and ophthalmologists will always be the key to successful comanagement of cataract patients.
While open communication aimed at ensuring the best possible outcomes remains the focus, other elements of comanagement are evolving in response to advances in refractive cataract care.
For instance, the control of postoperative inflammation has seen remarkable advances in recent years. In the not-too-distant past, most cataract patients presented on postop day 1 armed with three eyedrop bottles, numerous questions about each and a litany of reasons why complying with the prescribed regimen would be difficult. Today, exciting developments in pharmaceutical composition and administration enable patients to get excellent inflammation control with less reliance on eyedrops.
Standouts in this evolution are compounded, combination medications that enable inflammation control and infection prophylaxis in one drop, intraoperative sustained-release options that can be administered in lieu of topical drops and improved formulations of existing topical drugs that facilitate faster dissolution in the eye. All of these innovations serve to minimize the patient’s role in quieting postoperative inflammation.
Anti-inflammatory advances
In February 2018, Dexycu (dexamethasone intraocular suspension 9%, EyePoint Pharmaceuticals) became the first FDA-approved intraocular corticosteroid, administered as a single injection to treat postoperative inflammation. This was followed in August 2018 with the FDA’s approval of Inveltys (loteprednol etabonate ophthalmic suspension 1%, Kala Pharmaceuticals), a twice-daily topical steroid for the treatment of inflammation and pain after ocular surgery. In November 2018, Dextenza (dexamethasone ophthalmic insert 0.4 mg, Ocular Therapeutix) was approved as an intracanalicular insert to treat postoperative ocular pain; and a few months later in June 2019, the insert was approved for the treatment of ocular inflammation. More recently, in February 2019, Lotemax SM (loteprednol etabonate ophthalmic gel 0.38%, Bausch + Lomb) was approved for the treatment of postoperative inflammation and pain after ocular surgery.
Sustained delivery into or onto the eye essentially removes patient involvement in postoperative steroid administration. The two formulations of dexamethasone that are designed to be administered by surgeons — Dexycu into the posterior chamber and Dextenza into the lower punctum — are important for comanaging optometrists to know about.
Dexycu is a cohesive, bioerodible liquid steroid depot injected into the ciliary sulcus at the end of cataract surgery, where it delivers a tapering dose of dexamethasone for about 21 days. Dextenza delivers dexamethasone to the ocular surface for about 30 days via a resorbable hydrogel plug. In controlled clinical studies, both drugs provided a significant anti-inflammatory effect that began early and was sustained throughout the postoperative period (Donnenfeld et al., Tyson et al.).
Postop complexities
As part of effective comanagement in the postoperative period, it is imperative that we familiarize ourselves with all available anti-inflammatory medications and delivery modalities so we can effectively monitor progress and anticipate patients’ questions.
Ideally, patients will be provided with education about the cataract procedure and associated self-care measures they will be responsible for afterward. But postop care can be complicated, often involving multiple drops on different and sometimes tapering dosing schedules. Some patients have trouble remembering these complexities, and others have physical challenges to eyedrop administration.
When a complex drop regimen is required, I work with patients to find strategies that will help them comply. Examples include: setting an alarm on their phone, having a family member provide a text reminder, or engaging a family member or friend to help with administration directly in the event of physical limitations.
The use of single-dose, sustained-release options like Dexycu and Dextenza simplifies these discussions, and patients are generally very happy not to have an extra drop they need to track. I explain to them that not only do these sustained-release drugs reduce the burden on them, they also provide constant anti-inflammatory dosing, rather than the peaks and troughs that can occur with missed doses of topical medications.
In my experience with Dexycu, it is important to let patients know that the drug may be temporarily visible to them if it moves into the anterior chamber — this does not appear to affect its efficacy, and patients who notice it are not bothered. To aid visualization by the eye care practitioner, Dextenza is impregnated with fluorescein, but it is unlikely to be noticed by patients postoperatively.
Keeping communication open
Although cataract surgery is routine and generally very safe, patients are often alarmed and anxious to learn that they need an operation of any kind. It can be a comfort for them to be led through the pre- and postoperative visits with their familiar eye care provider and to know that communication with their surgeon is being taken care of by someone they know and trust. Educating patients about the medical aspect of optometric care is another benefit of comanagement.
Even as we continue to see pharmaceutical and technological advances in cataract surgery, comanagement will always rely on clear, open communication between the optometrist, surgeon and patient.
References:
- Donnenfeld ED, Holland E. Ophthalmol. 2018;doi:10.1016/j.ophtha.2017.12.029.
- Donnenfeld ED, et al. J Cataract Refract Surg. 2018;doi:10.1016/j.jcrs.2018.07.015.
- Tyson SL, et al. J Cataract Refract Surg. 2019;doi:10.1016/j.jcrs.2018.09.023.
For more information:
Jessica Heckman, OD, practices at Chu Vision Institute in Bloomington, Minn. She can be reached at: Jessica.Heckman@chuvision.com.
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