Challenges accompanying topical medications include poor patient compliance and the potential for ocular surface toxicity associated with some generic anti-inflammatory medications. Newer topical pharmaceutical options for inflammation control, including novel topical corticosteroids, target these concerns by incorporating advanced formulations that are more ocular surface friendly and allow for less frequent daily dosing. Intracameral corticosteroid administration during surgery represents another alternative to topical medications.
In the past surgeons have injected triamcinolone, but when placed into the anterior chamber, the cloudy suspension causes a “snowglobe” effect on vision. Injection through the zonules does not avoid the vision effect and is more likely to cause increased IOP, Dr. Trattler said.
The snow globe effect can be avoided with the off-label use of dexamethasone, which is a clear formulation. Now, however, surgeons can choose an FDA-approved intracameral dexamethasone product that is placed behind the iris at the end of surge (yDexycu, EyePoint Pharmaceuticals).
Using extended-release technology (Verisome) that releases dexamethasone for approximately 30 days, the product is designed to provide durable postoperative inflammation control. Another surgeon-placed dexamethasone product intended for intracanalicular insertion (Dextenza, Ocular Therapeutix) also releases medication over 30 days.
The product is a 3 mm cylindrical-shaped, resorbable, sterile insert placed into the lower lacrimal punctum. The insert is fluorescent, which allows confirmation of its presence in the punctum. Intracameral administration using the approved fixed combination of phenylephrine/ketorolac 1%/0.3% (Omidria, Omeros) placed into the irrigating solution is another newer medication management option.
Although the preservative- and bisulfite-free product is approved for preventing intraoperative miosis and reducing postoperative pain, Dr. Trattler suggested that the intraoperative bolus of nonsteroidal anti-inflammatory drug it delivers is also helpful for suppressing inflammation.
William D. Trattler, MD
Dr. Trattler is a consultant to EyePoint, Omeros, Ocular Therapeutix, and other companies that provide medications used perioperatively for cataract and refractive lens surgery.