It is agreed that controlling inflammation and managing infection risk, via steroids and NSAIDS and antibiotics, respectively, are of monumental importance following cataract surgery. In fact, the appropriate use of these medications drastically reduces the risk of post-cataract surgery complications, the most dreaded being endophthalmitis, reports an American Journal of Ophthalmology study.
Unfortunately, there are a number of barriers to the appropriate, or prescribed, use of these drugs, with, arguably, the largest one patient non-compliance: Specifically, many patients are unable to administer drops, due to mobility issues, poor installation technique, cognitive issues/poor memory and medication cost.
As a growing, busy collaborative care practice, we are constantly looking to improve the post-operative course of therapy. Thus far, we have been able to better our patient compliance numbers through the following three ways:
1 PROVIDING PERSONALIZED INDEX CARDS
We provide an 8.5 inch by 5.5 inch index card that contains the medication name (both branded and generic), cap color, the eye in which it is to be used and the dosing frequency. Further instructions on the card state to always use the medication(s) on the day of the visit, unless otherwise instructed. (See above.)
Also, directions on the index card state to close the eyes for 1 minute following drop administration, wait 5 minutes between instilling different drops and to never run out of medications unless directed by the doctor to instill until gone.
2 USING COMPOUNDED FORMULATIONS
One of the easiest ways to simplify drop use and, therefore, increase the likelihood of patient compliance, is to combine medications into a single bottle via an ophthalmic compounding pharmacy, such as ImprimisRx, OSRX and Avella.
Specifically, compounding pharmacies provide compounded formulations of the primary drug classes used during the perioperative period that can be provided through the practice. For example, one pharmacy offers prednisolone acetate, gatifloxacin and bromfenac: three drops in one formulation.
Advantages of this approach include:
- Eliminating the need for the patient to make a trip to the pharmacy.
- Fewer total drops (cataract patients can have cognitive issues and poor memory).
- Compounded medications may be more affordable.
- Less, possibly, of a deleterious effect (decreased preservative load) on the ocular surface, reducing the likelihood of patient discomfort.
Further, the practitioner knows exactly what formulation the patient is using, enabling the O.D. to determine its effectiveness. Finally, the practice staff is not inundated with calls from pharmacists regarding medication questions.
CATARACT SURGERY DROPS
- Fluorometholone acetate ophthalmic suspension 0.1%, (Flarex, Eyevance Pharmaceuticals)
- Loteprednol etabonate ophthalmic suspension 0.2%, (ALREX, Bausch + Lomb)
- Loteprednol etabonate ophthalmic gel 0.38%, (LOTEMAX SM, Bausch + Lomb)
- Loteprednol etabonate 0.5% ophthalmic suspension PF (Klarity-L, ImprimisRx)
- Difluprednate ophthalmic emulsion 0.05%, (DUREZOL, Novartis)
- Fluorometholone acetate ophthalmic suspension (FLAREX, Alcon)
- Fluorometholone ophthalmic ointment 0.1%, (FML, Allergan)
- Loteprednol etabonate ophthalmic suspension 1%, (INVELTYS, Kala Pharmaceuticals)
- Dexamethasone ophthalmic suspension 0.1% (MAXIDEX, Novartis)
- Prednisolone acetate ophthalmic suspension, USP 1%, (Pred Forte, Allergan)
- Prednisolone Acetate PF 1% (Pred Acetate, ImprimisRx)
- Rimexolone ophthalmic suspension, 1% (VEXOL, Alcon)
- Besifloxacin ophthalmic suspension 0.6% (BESIVANCE, Bausch + Lomb)
- Ciprofloxacin ophthalmic ointment 0.3% (CILOXAN, Novartis)
- Moxifloxacin Hydrochloride ophthalmic solution 0.5% (MOXEZA, ALCON)
- Moxifloxacin ophthalmic solution 0.5% (VIGAMOX, Novartis)
- Gatifloxacin ophthalmic solution 0.5% (ZYMAXID, ALLERGAN)
- Tobramycin ophthalmic ointment 0.3% (TOBREX, Novartis)
→ COMBINATION DROPS
- Gentamicin and prednisolone acetate ophthalmic suspension, 0.3%/1% (PRED-G, ALLERGAN)
- Loteprednol etabonate 0.5% and tobramycin 0.3% ophthalmic suspension (Zylet, Bausch + Lomb)
- Moxifloxacin 0/5% and bromfenac 0.0.54% (Moxi-Brom, ImprimisRx)
- Prednisolone acetate and bromfenac (Pred-Brom, ImprimisRX)
- Prednisolone acetate, gatifloxacin and bromfenac (Pred-Gati-Brom, ImprimisRx)
- Prednisolone acetate, gatifloxacin (Pred-Gati, ImprimisRx)
- Prednisolone, moxifloxacin (Pred-Moxi, ImprimisRX)
- Prednisolone, moxifloxacin, nepafenac (Pred-Moxi-Nepaf, ImprimisRx)
- Prednisolone, nepafenac (Pred-Nepaf, ImprimisRx)
- Sulfacetamide sodium and prednisolone acetate ophthalmic ointment, 10%/0.2% sterile (BLEPHAMIDE, ALLERGAN)
- Tobramycin/dexamethasone ophthalmic suspension 0.3%/0.05% (TobraDex ST, Novartis)
3 SUGGESTING DROP FREE, WHEN INDICATED
Not all cataract patients will be able to go drop free, particularly those patients who have diabetes and epiretinal membranes. This is because these patients have a higher risk of postoperative macular edema and, thus, tend to benefit from an NSAID.
For those cataract patients who can and have been identified as likely to be incompliant with the drop regimen, for whatever reason, the drop-free techniques of intracanalicular delivery, intracameral injection and transzonular injection are becoming increasingly available and embraced by surgeons:
- Intracanalicular delivery. DEXTENZA (dexamethasone ophthalmic insert 0.4 mg, Ocular Therapeutix) is indicated for the treatment of pain following cataract surgery. Inserted through the punctum and into the canaliculus immediately following surgery, it is preservative-free and dissolves over a 30-day period. The implant met both endpoints with a greater reduction in anterior chamber cells and absence of ocular pain compared to placebo during the Phase 3 clinical trial.
- Intracameral injection. DEXYCU (dexamethasone intraocular suspension 9%, EyePoint Pharmaceuticals) is a single-dose, sustained-release intracameral steroid for the treatment of postoperative cataract inflammation. The injected 5-uL droplet forms a sphere through surface tension in the anterior chamber and slowly releases dexamethasone over a 21-day period. The intracameral steroid was found safe and effective in treating inflammation post-cataract surgery, reports an Ophthalmology study.
- Transzonular injection. Tri-Moxi (triamcinolone 15 mg/ml and 1 mg/ml moxifloxacin, ImprimisRx) is a combination steroid/antibiotic, which may be injected via a transzonular or pars plana into the vitreous cavity at the time of surgery. High-risk patients, such as those who have epiretinal membranes, dense cataracts, diabetes, complicated past surgeries or a history of uveitis, may need a supplemental NSAID or even topical steroids. Finally, triamcinolone tends to cause floaters, so the optometrist should educate the patient of this and the fact that it will dissipate.
Co-management of all patients who undergo these drop-free procedures is comprised of making sure the eye is quieting nicely with no evidence of infection, and that the patient's vision is where it should be, based on the preoperative evaluation and IOL selected.
POST-OP CARE POINTERS
→ Compassionate post-operative care for our cataract patients is also crucial for maximizing their surgical experience. To accomplish this, we need to:
- Evaluate the cornea
- Obtain IOPs
- Obtain VAs
- Observe for any Seidel signs
- Inquire with patients that they are following the medication treatment exactly as prescribed.
→ As the patient’s post-op journey goes from day one to week one to month one, two or three, we must continue to monitor their improvement in vision, their tapering of drugs and their refractive status. IOP spikes, etc. can happen. (For information on complications and how to handle them, see https://bit.ly/ompostopcataract .)
- David Eldred, O.D.
MAKE IT EASY
Simplifying drop use raises the likelihood of patient compliance to the prescribed therapeutic regimen, increasing their post-operative success and, therefore, satisfaction in their care. OM