By Kevin M. Barber, MD, Special to Ophthalmology Times
Deland, FL—When a certain practice pattern has persisted over decades, it can be difficult to convince physicians to change.
However, this desire to cling to traditional techniques has more to do with habit than a basis in scientific data and literature. This struggle is currently occurring with medication following cataract surgery.
Traditionally, patients must endure weeks of a strict multi-drop regimen pre- and postoperatively. This confusing and often costly requirement typically results in dissatisfied patients, office staff, and physicians alike. Continually rising costs can at times reach up to $650 per eye,1 an amount few patients can manage. Even those who can obtain the correct drops often struggle with compliance.2,3
The drops are administered to prevent infection and inflammation, most notably endophthalmitis.
However, there is no solid scientific evidence that these drops actually aid in prevention. Conversely, studies have shown that while there is a statistically insignificant drop in the rate of endophthalmitis using topical therapies, occurrences of this condition are five times less likely to occur when medications are injected intracamerally.4,5
Injecting medications has also been shown to decrease the development of antibiotic resistance, which is a common occurrence in topical antibiotic applications.6-8
If injecting these medications intracamerally produces such exceptional results, it stands to reason that injecting intravitreally will work even better. Studies have shown intravitreal injections of triamcinolone acetonide and moxifloxacin hydrochloride (Tri-Moxi, Imprimis Pharmaceuticals) and triamcinolone-moxifloxacin-vancomycin (Tri-Moxi-Vanc, Imprimis) not only reduce rates of infection and inflammation, and nearly eliminate endophthalmitis, but significantly reduce occurrences of cystoid macular edema (CME) as well.9,10
Yet, the ophthalmic surgical community as a whole continues to cling to traditional methods, despite science pointing to a superior technique. It is time for a paradigm shift.
Addressing surgeons’ concerns
In addition to combating decades’ worth of training and experience with topical therapies, many surgeons may hesitate due to the compounded nature of these injections.
However, the reality is compounded medications—such as an epinephrine and lidocaine concoction—are used on a regular basis in ocular surgery. Concerns with these new compounds may also stem from the slightly higher risk of injecting into the vitreous, though published studies show the benefits far outweigh any risks.9,10
Other concerns may be related to a policy modified in January 2015 where CMS took the position that dropless therapy is both “covered” and paid for, since it is part of the surgery and the surgery is covered and paid for through the facility fee. Surgeons need for CMS to understand that the actual cataract surgery is unchanged by dropless therapy, which is simply an alternative means of administering post-surgical drops which are covered under Medicare Part D. Through a Cataract Surgeons for Improved Eyecare (CSIE) (improvedeyecare.org) co-sponsored study data supports that dropless therapy could save CMS over $7 billion in a ten-year period while saving patients $1.4 billion in out-of-pocket copayment costs.11
In the meantime, the use and popularity of dropless therapy continues to rise and more and more patients are demanding this procedure. Today the small cost of dropless therapy is offset by the cost saved in increased patient recommendations and staff productivity. Word of mouth is spreading and patients are seeking out surgeons who utilize the dropless approach.
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Additionally, many physicians may not realize the amount of time their staff spends on drop issues.
In my own practice, it was necessary to employ a full-time triage technician who spent 75% of the time just on drop concerns from patients, insurance providers, and pharmacies. With the implementation of the intravitreal injection into my surgical procedure, this technician can now focus on more productive endeavors.
I perform 95% of my injections transzonularly. This is my preferred approach as I am already in the eye and do not need to create another injection site. The important issue here is to carefully manipulate the cannula in order to get it posterior enough that the medication stays in the vitreous and does not reflux back into the anterior chamber. However, the ciliary body must be avoided or it is possible to cause a hemorrhage or hyphema.
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I will utilize a pars plana approach for my high hyperopic patients with a short axial length, typically less than 22 mm, as they are at higher risk for iris prolapse due to smaller vitreous volume. In these cases, I go in through the pars plana and “burp” the wound to bring the pressure down. This technique has been well tolerated by patients.
One of the most important steps is educating not only patients, but also staff members as to what to expect post procedure. Patients may experience floaters for up to a few days post surgery as the medication slowly dissipates. Staff members have been traditionally trained to be aware of floaters as they may indicate the risk of a retinal tear or detachment. As long as staff members and patients are aware that floaters after a dropless procedure are normal, concerns are generally minimal.
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In my own practice, an educational sheet for patients explains the difference between floaters caused by injected medication and those that may indicate retinal problems. Those caused by medication are generally superior and blob-like in shape and should continue to dissipate as time goes on. Floaters caused by injected medication are not typically associated with flashes of light.
Experience with dropless therapy
Dropless therapy has been intriguing from my first exposure a decade ago while in Ethiopia, where intracameral or intraocular injections are utilized to combat the cost and availability barriers to the patients there. The results were impressive. When I discovered the intravitreal method of injecting triamcinolone-moxifloxacin-vancomycin about 18 months ago, I quickly went from offering it as an option to making it a standard of care for nearly all patients.
The small percentage of patients who do not receive this therapy are typically advanced-stage glaucoma patients who are already on maximum medical therapy and have significant nerve damage, and who could not tolerate a steroid response if one occurred. Though these responses are few and far between, I prefer to err on the side of caution where these patients are concerned. For monocular patients, I provide the facts of the slight vision lag they may experience due to floaters post-procedure and give them the choice on whether to receive the injection or traditional drops. Nearly all have elected for the dropless approach.
Bottom line: though there may be a few minor drawbacks, these do not outweigh the basic reality that this is the best therapy for the patient. The approach alleviates anxiety, cost burden, and adherence associated with traditional drop therapy, and has been scientifically documented to provide improved infection and inflammation prevention than previous methods.
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1. Andrew Chang and Co., LLC. “Analysis of the Economic Impacts of Dropless Cataract Therapy on Medicare, Medicaid, State Governments, and Patient Costs.” October 2015.
2. Stone JL, Robin AL, Novack GD, Covert DW, Cagle GD. An Objective Evaluation of Eyedrop Instillation in Patients With Glaucoma. Arch Ophthalmol. 2009;127:732-736.
3. Schwartz GF, Hollander DA, Williams JM. Evaluation of eye drop administration technique in patients with glaucoma or ocular hypertension. Curr Med Res Opin. 2013;29:1515-1522.
4. Barry P, et al. ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery: Preliminary report of principal results from a European multicenter study. J Cataract Refract Surg. 2006;32:407-410.
5. Shorstein NH, Winthrop KL, Harrinton LJ. Decreased postoperative endophthalmitis rate after institution of intracameral antibiotics in a Northern California eye department. J Cataract Refract Surg. 2013;39:8-14.
6. Kim SJ, Toma HS. Antimicrobial resistance and ophthalmic antibiotics: 1-year results of a longitudinal controlled study of patients undergoing intravitreal injections. Arch Ophthalmol. 2011;129:1180-1188.
7. Hwang DG. Fluoroquinolone resistance in ophthalmology and the potential role for newer ophthalmic fluoroquinolones. Surv Ophthalmol. 2004; 49 Suppl 2:S79-S83.
8. Gaynor BD, Chidambaram JD, Cevallos V. et al. Topical ocular antibiotics induce bacterial resistance at extraocular sites. Br J Ophthalmol. 2005;89:1097–1099.
9. Liegner J. Better surgery through chemicals. Presented at the American Society for Cataract and Refractive Surgery Annual Meeting. April 25-29, 2014. Boston.
10. Galloway MS. Intravitreal placement of antibiotic/steroid as a substitute for post-operative drops following cataract surgery. Presented at the American Society for Cataract and Refractive Surgery Annual Meeting. April 25-29, 2014. Boston.
11. Andrew Chang and Co., LLC. “Analysis of the Economic Impacts of Dropless Cataract Therapy on Medicare, Medicaid, State Governments, and Patient Costs.” October 2015.