
This article was reviewed by Matthew S. Wieder, MD



Use of anxiety screening questionnaires in patients needing intravitreal anti-vascular endothelial growth factor (VEGF) injections may help to identify individuals at risk for elevated pain during the procedure, according to results of a study.

The 2-center, noninterventional, prospective study was designed to evaluate anxiety levels and sleep patterns as predictors of patient perceptions of pain following intravitreal bevacizumab injection. 

ASRS 2020: Diabetic retinopathy progression in anti-VEGF versus FA implant

In a regression analysis that controlled for potential confounders, anxiety score measured with the General Anxiety Disorder-7 (GAD-7) questionnaire was the only variable examined that independently predicted pain.

There were no statistically significant associations between intravitreal anti-VEGF injection pain and measured sleep parameters, age, gender, laterality, diagnosis, previous injections, or surgeon/site.

Intravitreal anti-VEGF injections are the most commonly performed in-office intraocular procedure, according to Matthew S. Wieder, MD

“Although generally well tolerated, some patients experience pain, and because many patients undergo these treatments on a regular basis for treatment of a chronic condition, pain during the injection could result in poor adherence to future treatment,” he said. “To identify strategies to combat the pain experienced by some patients, several studies have evaluated different techniques to decrease the pain, including changes in anesthesia and injection site.”

According to Wieder, a resident in the Department of Ophthalmology and Visual Sciences at the Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York:

“The findings of our study support future research of modifications that target anxiety to help address pain perception of intravitreal anti-VEGF injections.”

Evaluating the change in VA, CMT after early switch of anti-VEGF drugs

Wieder presented the study at the Association for Research in Vision and Ophthalmology (ARVO) 2020 virtual annual meeting.

Moshe Szlechter, MD, and Irene Rusu, MD, performed the injections. Szlechter is a retina specialist at KLM Eye Care, Brooklyn, New York, and Rusu is a retina specialist at Brooklyn Eye Center, also in Brooklyn. 

Both are assistant professors of ophthalmology and visual sciences at Albert Einstein College of Medicine, Bronx, New York.

Szlechter said the idea for the study occurred to him while he was lecturing in his community about ophthalmology procedures.

“I wound up speaking from the hip and said that I can predict based on a patient’s level of stress who will feel pain before I even administer the injection,” he noted. “I researched the idea after my lecture and found no good data to support my assertion.”

Szlechter added that it can be interesting to see how a psychological state influences a very physiological reaction.

“A patient’s heightened anticipation and anxiety of future pain will actually make the procedure more painful,” he said.

Anti-VEGF therapy may prevent/delay radiation maculopathy in choroidal melanoma


A standard technique was used at the two participating sites to control for potential confounding variables. Patients were given the GAD-7 (possible range 0-21) and Pittsburgh Sleep Quality Index (PSQI; possible range 0-21) to complete prior to their injection.

After the procedure, they were asked to rate the severity of pain after intravitreal injection as 0 to 10 with a visual analog scale.

A total of 154 patients were recruited, of which 140 met the inclusion criteria for analysis. The total cohort was equally distributed between the 2 sites. The patients included in the analysis had a mean age of approximately 72 years and 56% were women.

The 2 most common indications for the injections were wet age-related macular degeneration (40%) and diabetic macular edema (29%). 

Mean ± standard deviation scores were 4.9 ± 5.6 for the GAD-7, 6.3 ± 4.1 for the PSQI, and 3.69 ± 2.64 for pain. 

Mean ± standard deviation for overnight sleep was 6.7 ± 2.0 hours and was 7.6 ± 2.6 hours for sleep more than 24 hours.

What keeps you up at night in ophthalmology?

“Anxiety scores on the GAD-7 ranged from 0 to 21 and postprocedure pain scores ranged from 0 to 10, but most patients had low scores indicating mild to no anxiety and most experienced no or mild pain,” Wieder said.

A statistically significant positive correlation was found between the GAD-7 score and pain.

For the sleep measures, both previous night’s sleep and sleep over the previous 24 hours negatively correlated with pain, and there was a positive correlation between PSQI and pain scores (higher PSQI score indicates poorer sleep quality), although none of the correlations achieved statistical significance. In the regression analysis that controlled for confounding variables, each point increase in the GAD-7 score predicted a 0.11-point increase in procedural pain score, according to Wieder.


Wieder has no relevant financial interest to declare.


Szlechter has no relevant financial interest to declare.


Mbekeani has no relevant financial interest to declare.

Articles

Study points to possible role of addressing preprocedural anxiety


Improve patient comfort with intravitreal injections

This article was reviewed by Christopher D. Riemann, MD



Subretinal transplantation of human embryonic stem cells-derived retinal pigment epithelial (RPE) cells in patients with 

 and geographic atrophy (GA) appears well tolerated, according to Christopher D. Riemann, MD, of Cincinnati Eye Institute and University of Cincinnati in Ohio. 

During the Association for Research in Vision and Ophthalmology virtual annual meeting, he presented interim results of a phase I/IIa trial investigating OpRegen for the treatment of dry AMD with GA (

Phase 1 trial investigating novel gene therapy for neovascular AMD

OpRegen is administered as a cell suspension, initially in a balanced salt solution but now in a thaw-and-inject formulation using CryoStor 5. 

The US Food and Drug Administration has already granted OpRegen fast track designation, Riemann said.

RPE cell replacement is important because loss of RPE cells impairs drusen clearance, leading to the development of macular degeneration and corresponding central vision loss.

The trial’s primary objective was to assess the safety and tolerability of subretinally transplanted stem cell–derived RPE cells in patients with dry AMD and GA. The secondary objective looked at the cells’ survival and possible effects of OpRegen treatment by assessing changes in retinal structure and function.

Research shows promising results for LHON gene therapy


The trial has 4 cohorts with advanced dry AMD and GA. Cohorts 1, 2, and 3 include 12 legally blind patients (visual acuity, < 20/200); cohort 4, which will include patients with better visual acuity and smaller atrophy (average visual acuity, 20/125), is still recruiting, with 5 of 12 patients enrolled. (

Patients underwent short-course, perioperative systemic immunosuppression prior to the procedure. 

The eyes with the poorest vision were implanted with 50,000 to 200,000 OpRegen cells subretinally in suspension either through a standard approach with pars plana vitrectomy and retinotomy or using the Gyroscope Therapeutics Orbit Subretinal Delivery System (SDS).

“The Orbit Subretinal Delivery System is a new surgical procedure using novel instrumentation,” Riemann said. “A sclerotomy is created, [and] a special cannula is placed tangentially into the suprachoroidal space and advanced posteriorly toward the target area in the macula, adjacent to the geographic atrophy.”

Contrast sensitivity shows potential for measuring visual function loss in early AMD

​ When the target area is reached, “a screw drive advances a needle through the choroid into the subretinal space,” he said. Next, a leading balanced salt solution subretinal bleb is created.

“Once we confirm a subretinal bleb, we turn a valve and switch from balanced salt solution to cells and deliver the OpRegen into the subretinal space,” Riemann said. “The subretinal injection is accomplished without a vitrectomy or retinotomy.”


Patients in cohorts 1, 2, and 3 had no marked, sustained reductions in visual acuity. The 5 patients in cohort 4, however, had improved vision up to the 1-year follow-up period, including 1 patient who experienced a 10-letter gain that was sustained for 15 months.

“Improvements in drusen retinal outer layers and retinal pigment epithelium within the area of OpRegen transplant were observed and have persisted in some patients,” Riemann said. 
“Asymmetrical progression of geographic atrophy in the treated areas has been observed. The change in the total area is trending toward slower growth in treated versus fellow eyes. Better visual acuity and improved reading speed have been observed in some early cohort patients and all cohort 4 patients after OpRegen.”

AMD, DED most common retinal conditions in the United States


There were no reports of acute or delayed inflammation or increases in interocular pressure, but all patients reported at least 1 adverse event (AE). For systemic AEs, asthenia and malaise were reported by 4 patients.

“Subretinal pigmentation was common and presented in 11 out of 17 patients,” Riemann said. “[Although] the significance of this remains unclear, we believe it may represent a potentially positive finding as evidence of long-term survival of the subretinally transplanted OpRegen cells.”

Of note, among patients who received vitrectomy and retinotomy, 1 had a retinal detachment (successfully repaired) and 13 of 15 patients developed or experienced an exacerbation of an existing epiretinal membrane; 1 resulted in a temporary reduction in vision and required a vitrectomy, after which vision was restored.

“[Although] visual acuity improved after the peeling, the need for the vitrectomy to remove the epiretinal membrane is important,” Riemann said. “Though the cause of these epiretinal membranes remains unclear, we felt as if a possible etiology may have been migration of the OpRegen cells through the retinotomy in the vitreous cavity post transplantation, and this was an important underlying reason for us to explore the Orbit Subretinal Delivery System for transplantation of the OpRegen cells without a vitrectomy or retinotomy.”

FDA grants fourth ODD for treatment of gene mutation-associated retinal diseases

Neither of the 2 cohort 4 patients operated on with the Orbit SDS have developed epiretinal membrane, macular pucker, lamellar hole, retinoschisis, or retinal detachment. 

However, patients in the Orbit SDS group developed small, asymptomatic subretinal hemorrhages that resolved on their own. The significance of that AE is unknown. 

513/984-5133
This article is adapted from Rieman’s virtual presentation at ARVO 2020. He has no financial disclosures related to this content.

Patients underwent short-course, perioperative systemic immunosuppression prior to procedure


Stem cells for dry AMD with GA show promise in early study

This article was reviewed by Heba Mahjoub, BS



Ophthalmologists have a way to be more active in educating their patients: A recent analysis of a subreddit on eye triage indicated that patients are seeking information from other patients and optometrists rather than ophthalmologists.

Evidence shows that patients are turning increasingly to social media to get medical information. 

One of these outlets is Reddit, a popular, growing platform that allows users to share stories, seek and post information, and engage in discussions with other users on every topic imaginable.

How to reach glaucoma patients through social media

Patients have sought information on medical topics such as urinary incontinence, rheumatoid arthritis, human papillomavirus, and underage use of Juul products, according to Heba Mahjoub, BS, and colleagues Shameema Sikder, MD, at Johns Hopkins University in Baltimore, Maryland, and Arpan Prabhu, MD, at the University of Arkansas for Medical Sciences in Little Rock.

Mahjoub is a medical student at Johns Hopkins School of Medicine in Baltimore.

To determine patient concerns, improve online sources of patient education, and help predict and circumvent areas of confusion before patients depart from a clinical appointment, the investigators wanted to understand what information patients were seeking on ophthalmologic topics on the subreddit “eyetriage,” created in January 2019 (reddit.com/r/eyetriage). 

This subreddit focuses on patient concerns rather than ophthalmologists who share information among themselves.

Mahjoub and her colleagues manually collected and assessed the first 22 posts and their first 3 comments in each month of 2019. 

Leveraging social media to expand keratoconus awareness



The posts were sorted by date and time, type, content, emotional tone, and numbers of upvotes and reply comments. 

The reply comments, the investigators explained, were characterized based on content, emotional tone, time of comment, and user background.

Two authors independently reviewed and coded all posts for inclusion in the final database.


The investigators analyzed 200 posts and 456 replies. The vast majority of posts, 198 (99%), were questions—another post was information and another was humorous—and 26 (13%) included an image. Thirty-two unique post codes were generated, along with 11 reply comment codes, Mahjoub reported.

“Regarding the post codes, the most common codes were seeking diagnosis [21.0%], surgical complication [11.5%], and alternative medication options [6.50%],” she said.

Others included surgical options (5%), blurred vision (4%), and trauma-induced deficits (4%). 

When possible, the investigators identified the users who replied to each post. 

) were from self-identified patients (36%), optometrists (33%), and ophthalmologists (11%); others included unspecified users (9%), optometry students (3%), and certified ophthalmologist assistants (2%).

The top comment codes for the replies were treatment advice (34.7%), advice deferred to other health specialists (15.4%), and sharing information (13.2%).

Pearls to educate patients about ocular telemedicine options


“The results provide some insight into what ophthalmology patients are asking online,” Mahjoub said.

Clarification of diagnoses was one theme identified. Based on this, the investigators speculated about the helpfulness of giving ophthalmology patients access to clinic notes to help clear any confusion.

The legal ramifications of sharing medical advice online was also highlighted. Some providers, Mahjoub pointed out, might be cautious about so doing out of fear of misguiding patients who had not been assessed during an appointment. 

“It is important to use social media as a supplemental tool rather than as a substitute for an inpatient appointment,” she emphasized.

Another aspect is that providers who are cautious about misguiding patients might use social media to educate one another in clinical practice and academia, she said.


Apps now online to aid patients with visual impairment




Finally, Mahjoub pointed out, controversy may exist about using social media because providers view this as an encroachment on their fields.

“It will be interesting to see the role of social media in future practice,” she said.

“The results showed that there clearly is a growing need for medical professionals to advise patients online in a regulated manner. Incorporation of board-certified ophthalmic providers could ease the patient burden and clarify the source of most patients’ concerns before they leave a medical appointment. This realm has the potential to be advertised by various ophthalmic societies, such as the American Academy of Ophthalmology.” 


Mahjoub has no financial interest in this subject matter.

Social media sites offer physicians an opportunity for patient education.


Ophthalmology taking the treatment conversation online


In a validation study of the software’s algorithm, investigators reported that the iris registration from preoperative keratometry and steep axis values measurement enables identification of the patient’s steep axis within 2 degrees of actual cyclorotation in the Catalys user interface in 94% of eyes.

Big data drives opportunity for real-world evidence



Used to make relaxing incisions or corneal marks for toric IOLs, the astigmatism management function saves time and allows for a more efficient workflow, according to the findings.

It is known that astigmatism reduces distance and near visual acuity, vision quality, and depth perception.

It has been shown that 38% of US patients with cataracts have astigmatism (≥ 1.00 D).

Due in part to limitations in the currently available diagnostic and surgical methods for the surgical correction of astigmatism, it often goes undercorrected or uncorrected.

Astigmatism: A ‘clear-as-mud’ concept to patients


To assess the accuracy of the femtosecond laser artificial intelligence (AI) algorithm for measuring cyclotorsion in cataract surgery, Douglas D. Koch, MD, and colleagues compared an initial set of data with the reference, or truth, then applied the AI methodology.

Koch, professor and the Allen, Mosbacher, and Law Chairman in Ophthalmology, Cullen Eye Institute, Baylor College of Medicine, Houston, presented the results of this investigation during the American Society of Cataract and Refractive Surgery 2020 virtual annual meeting.

The team used a set of 52 eyes to refine and develop the software, then validated the algorithm with a set of 49 eyes. 

Preoperative images and data from undilated eyes were measured by the Cassini and matched with images of dilated eyes captured when docked to the Catalys. 



Teaching AI algorithms to identify corneal pathology: The future is now

The goal was to register at least 90% of images and achieve an accuracy within 2 degrees, Koch said.

“For the development set, 3 human graders manually graded the Cassini and Catalys images to define true cyclorotation,” he noted. “This set had to have a standard deviation of <2.5 degrees to be included, and for docking, the eye was centered ±2.3 mm within the liquid optics interface of the suction ring.”

The system’s iris registration software automatically compensates for cyclorotation, displaying on the screen the amount of rotation and the alignment coordinates. It then indicates a “quality factor” of “strong match,” “limited match,” or “failed match.”

“For the validation eyes, we compared data from the iris registration software with images classified by 5 graders,” Koch said. “We found that 96% of these eyes (47 of 49) were registered with acceptable quality readings. For the 2 eyes that failed according to the software, the surgeon was notified to ensure manual marking. We also found that 98% of the registered eyes, 46 of 47, were accurate within 2 degrees.”

The software offers an extremely accurate option for astigmatism management, allowing femtosecond laser cataract surgery to fulfill its promise of enhanced precision.

“This step forward cements the technology’s benefit for patients in terms of more exact outcomes, and it introduces time-saving elements for surgeons as well,” Koch said.



Macular OCT imaging is vital in work-up of cataract surgery patients


The software creates a streamlined workflow, speeds up the surgical process, and improves accuracy. Specifically, with direct entry of preoperative data, the software minimizes data entry verification and manual transcription errors, according to the manufacturer. 

Because it includes automatic calculations of the arcuate incision parameters into the treatment planning screen with a built-in nomogram, time spent on calculations is reduced.

The system eliminates the need for intraoperative registration systems by creating radial laser marks for toric IOL alignment with the laser that provide more precise alignment than do manual ink marks.

The collaboration with Cassini for iris registration with automatic cyclorotation compensation further serves to refine the accuracy of astigmatic outcomes, according to Johnson & Johnson Vision.



Toric stability: A minor change with a major impact for patients

Koch explained that although data show that manual marking can certainly be precise, it allows for virtually no margin of error.

“To me, this means making the marks and then diagramming the precise location of the marks in a drawing to be taken into the operating room,” he said. “Those steps consume surgeon time.”

Now, with the software’s iris registration capabilities, surgeons can dock the patient and let the astigmatism management software find the desired alignment meridian and create the marks as part of the procedure, he said. The software will alert the surgeon if it is unable to obtain alignment.

“The robustness of the iris registration capability of Catalys is exciting, particularly remembering that we matched preoperative undilated eyes to dilated images obtained when the eye was docked using the liquid interface,” Koch concluded. “I am impressed by the fact that the system can so accurately look at an undilated pupil, in air, and compare it with a dilated pupil in fluid.” 


1. Wolffsohn JS, Bhogal G, Shah S. Effect of uncorrected astigmatism on vision. 

 2011;37(3):454-460. doi:10.1016/j.jcrs.2010.09.022

2. Read SA, Vincent SJ, Collins MJ. The visual and functional impacts of astigmatism and its clinical management. 

. 2014;34(3):267-294. doi:10.1111/opo.12128

3. Hill WE. Prevalence of corneal astigmatism prior to cataract surgery. East Valley Ophthalmology.https://www.doctor-hill.com/iol-main/astigmatism_chart.htm

4. Koch DD, Wang L, Vogels J, Dewey D. Evaluation of intraocular pressure change after the femtosecond laser procedure for cataract surgery. Paper presented at: American Society of Cataract and Refractive Surgery Virtual Annual Meeting; May 16-17, 2020. https://beta.ascrs.org/clinical-education/cataract/2020-pod-sps-103-65609-assessment-of-the-accuracy-of-an-iris-registration-algorithm-of-a-f

5. Visser N, Berendschot TTJM, Bauer NJC, et al. Accuracy of toric intraocular lens implantation in cataract and refractive surgery. 

. 2011;37(8):1394-1402. doi:10.1016/j.jcrs.2011.02.024

6. Dick HB, Schultz T. Laser-assisted marking for toric intraocular lens alignment. 

. 2016;42(1):7-10. doi:10.1016/j.jcrs.2015.12.004

Newly cleared technology for laser cataract gives ophthalmologists another tool.

Astigmatism management software proving to be accurate, precise 


This article was reviewed by Emily Schoemmell

Patients responding to a survey conducted by Ora Inc communicated general dissatisfaction with the efficacy of their eye drops. 

Specifically, they said they believe that their eye drops are effective only some of the time or not at all.

The 64 respondents had participated in an ocular allergy clinical trial and were part of its database. 

They were asked to respond to a questionnaire to assess the degree to which ocular allergies affect their quality of life, said Emily Schoemmell, manager, allergy, at Ora, Inc.

New molecule for allergic conjunctivitis makes debut

Survey participants, with a mean age of 50.4 years and of whom 70% were women, were residents of Massachusetts, New Hampshire, New York, and Florida. Of the total number of patients, 70% were women; 74%, Caucasian; 20%, Hispanic/Latino; and 6%, Black.

According to Schoemmell, almost 98% of respondents had nasal and ocular allergy symptoms, and smaller percentages reported experiencing other types of allergies, such as related to food (17%), skin (30%), and drug (10%).

The group’s reported symptoms are representative of national trends, Schoemmell said. She noted that 50% and 47% of patients experience nasal and ocular allergies, respectively, all year. 

When broken down by season, 48% of patients have nasal (35%) and ocular (48%) symptoms in the spring compared with 0% and 2%, respectively, in the winter. “For most patients, allergies are triggered by either pollen or dust mites,” she said.

Making dry eye manageable for patients working from home

When asked to rank their top 3 complaints associated with ocular allergy, participants listed ocular itching (60%), excessive tearing or watery eyes (27%), and ocular redness (18%). 

When patients were asked to rate the impact on daily activities using a scale of 0 (no problem) to 6 (extremely bothersome), many gave scores of 5 or 6. “The inability to perform outdoor activities was the top complaint,” she said.

Almost three-quarters of patients reported never seeking treatment from their physicians. Most used OTC drops for nasal and ocular allergies and judged the products to be effective some or none of the time.

The questionnaire also collected data on dry eye, for which 41% of the survey respondents reported symptoms. 

Myths and misconceptions about autologous serum for dry eye

According to Schoemmell, over the various periods the survey was conducted nationwide during the past 6 years, most patients said that eye drops are effective only some of the time or not at all for treating their allergy symptoms. ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 



Schoemmell is manager, Allergy Department, at Ora Inc.

Surveyed patients express dissatisfaction with efficacy of eye drops.

Examining ocular allergy, quality of life


This article was reviewed by Tracy W. Krick, MD



When the postoperative rates of endophthalmitis between brands and types of topical antibiotics are compared, no single antibiotic has clear superiority over another. 

This finding may lead to an opportunity for patients to cut costs by using less expensive antibiotics after 

Most cataract surgeons prescribe perioperative topical antibiotics to prevent infections after procedures. Numerous options are available, and their costs also vary widely. 

Battling endophthalmitis: New bugs, new technologies, new drugs

Interestingly, there is little information regarding the rates of endophthalmitis infections associated with the various topical antibiotics.

In light of that, Tracy W. Krick, MD, and associates compared the postoperative rates of endophthalmitis among patients who had been treated with different types of antibiotics after 

The investigators also sought to determine prescribing patterns and the costs associated with the topical antibiotics.

This study was a cross-sectional analysis of Medicare patients who had Part D coverage and underwent cataract surgery in 2016. The investigators analyzed the rates of endophthalmitis within 90 days after surgery.

The results showed that endophthalmitis rates were strikingly similar in almost 600,000 patients using different types of topical antibiotics: 0.10% with fluoroquinolones, including ofloxacin, moxifloxacin, and besifloxacin, which accounted for about 35%, 15%, and 10.7%, respectively, of patients; 0.09% with polymyxins; and 0.12% with aminoglycosides, Krick reported.

Endophthalmitis detection by whole genome sequencing and qPCR

“The rates of endophthalmitis were low regardless of the type of topical antibiotics prescribed. Overall, there was no clinically significant difference in the rates of endophthalmitis among patients prescribed different classes of antibiotics,” she said.

The investigators found that 66.6% of drugs were generics and the remainder were brand-name drugs. 

Again, the rates of endophthalmitis were nearly the same, at 0.07% and 0.08%, respectively. “Overall, this represents no clinically significant difference between the generic and branded drugs,” Krick said.


One major difference between the 2 types of medications was cost, with branded drugs
accounting for 80% of the cost of the antibiotics, according to Krick:

“The total cost of topical antibiotics prescribed for 

 in 2016 was about $42.8 million. Of this number, branded moxifloxacin and besifloxacin commanded the lion’s share, at over $21 million and $12 million, respectively.”

Topical moxifloxacin: Best choice before cataract surgery?

The investigators calculated that if generic drugs were substituted for the directly equivalent branded prescriptions, the savings would exceed a whopping $14 million.

“If one is willing to make substitutions among the different types of fluoroquinolones, the potential annual savings are ever greater,” Krick said. With about $35 million spent on ciprofloxacin, gatifloxacin, levofloxacin, moxifloxacin, and besifloxacin currently, substituting generic for the other types of fluoroquinolones would save more than $29 million in 1 year.

“Our initial analyses did not show a clear superiority of 1 topical antibiotic over another. However, we could not account for the use of intracameral antibiotics, and the study had limitations of claims data, which lack granularity,” Krick said.

In recent years, intraoperative intracameral antibiotics emerged as an alternative to perioperative topical antibiotics. 

The 2013 European Society of Cataract and Refractive Surgeons guidelines for prevention of endophthalmitis and the American Academy of Ophthalmology’s 2016 Cataract Preferred Practice Patterns concluded that intracameral antibiotics are an effective method of endophthalmitis prophylaxis. 

ASCRS 2020: Assessing effectiveness of intracameral phenylephrine/ketorolac post-cataract surgery

A growing body of evidence, including a prospective treatment study by the ESCRS Endophthalmitis Study Group, found that intracameral antibiotics more effectively reduce the risk of endophthalmitis compared with topical antibiotics.

“Our study was unable to evaluate the use and costs of intracameral antibiotics due to different payment mechanism for drugs used during surgery versus outpatient use in the Medicare system,” Krick commented. “[Although] there is a potential to save a great deal of money by prescribing generic brands over brand-name topical antibiotics, further research is needed to elucidate the best practice that would improve the value of care delivered to patients.” 

Krick has no financial interests in this subject matter. She is a resident at the Wilmer Eye Institute at Johns Hopkins Medicine in Baltimore, Maryland.

A number of options may offer major cost savings, positive results for patients.

Research: Similar endophthalmitis rates for generic, branded topical antibiotics

This article was reviewed by Mitchell A. Jackson, MD

Premarketing studies investigating phenylephrine and ketorolac intraocular solution 1%/0.3% (Omidria, Omeros) provided evidence leading to the product’s approval for maintaining pupil size by preventing intraoperative miosis during 

 replacement and reducing postoperative ocular pain.

Now, a growing number of real-world studies document that the combined actions of the 2 ingredients translate into additional clinically meaningful benefits. 

Perioperative medications can eliminate postoperative drops after cataract surgery

For those reasons, leading surgeons value phenylephrine/ketorolac as a core component in all 

“I do not operate without phenylephrine/ketorolac because it facilitates the procedure from beginning to end in routine and complicated cases,” said Mitchell A. Jackson, MD, the founder and CEO of Jacksoneye in Lake Villa, Illinois.

According to Jackson, using phenylephrine/ketorolac makes the entire case easier.

“It minimizes the potential for unnecessary additional surgical trauma, the risk of complications, and the need for ancillary strategies to address small pupils,” he said. “Phenylephrine/ketorolac also increases efficiency and can improve facility profitability.”

In 2018, Steven M. Silverstein, MD, published findings from a double-blind, randomized, placebo-controlled study demonstrating the efficacy of intracameral phenylephrine/ketorolac for maintaining pupil dilation and preventing iris billowing and prolapse in patients taking tamsulosin who were at risk for intraoperative floppy iris syndrome (IFIS).

® that he uses the product in all of his cataract surgery cases and not just for patients at high risk for pupil issues intraoperatively.

“I certainly appreciate having phenylephrine in the eye to maintain pupil mydriasis, but I think it is also especially valuable that ketorolac is present and bathing uveal tissue at the time when surgical trauma first occurs,” said Silverstein, president of Silverstein Eye Centers in Kansas City, Missouri, and clinical professor of ophthalmology at Kansas City University of Medicine and Biosciences in Kansas City.

“Ketorolac blocks production of prostaglandins that lead to corneal edema, anterior chamber inflammation, and cystoid macular edema (CME),” he said. “As a result, patients benefit with greater comfort, quieter eyes, and more rapid visual recovery, which together translate into greater patient satisfaction.”

Jackson agreed. He said he does a lot of femtosecond laser–assisted cataract surgery, and the femtosecond laser treatment causes release of prostaglandins that can cause faster intraoperative miosis.

“Injecting phenylephrine/ketorolac intracamerally at the start of the case and adding it to the irrigating solution minimizes that concern,” he said.


Silverstein said he chose to study the use of intracameral phenylephrine/ketorolac in patients at risk for IFIS because individuals who were on an α1-receptor antagonist were excluded from participating in the phenylephrine/ketorolac premarketing clinical trials. 

His study protocol was novel in that every case was digitally recorded externally from the perspective of the operating microscope and internally using an endocyclophotocoagulation probe.

The video content was analyzed using sophisticated software to obtain accurate and objective measurements of pupil size, iris billowing, and iris flaccidity that allowed him to create a grading scale of iris billowing severity.

Benefits of intracameral phenylephrine/ketorolac continue to add up. 


Ophthalmology Times: September 1, 2020

Improve patient comfort with intravitreal injections

Stem cells for dry AMD with GA show promise in early study

Ophthalmology taking the treatment conversation online

Astigmatism management software proving to be accurate, precise

Examining ocular allergy, quality of life

Research: Similar endophthalmitis rates for generic, branded topical antibiotics

Improving surgical safety, efficiency, and outcomes for patients

FAF shedding light on patterns related to disease chronicity in CSC

IOL offering treatment options for ophthalmologists

Unproductive worry: Conquering fear during a pandemic

Are posterior corneal curvature changes culprit in hyperopic shifts?

A new pair of eyes

DMEK in 'super' seniors: feasible treatment, realistic expectations

Working out the mystery of ectasia risk with artificial intelligence

Researchers: Protocol V findings offer physicians guidance for managing DME

Dispelling myths about refractive lens exchange