Eliminating uncertainty from the postoperative care regiment by providing inflammation control with a depot steroid can make a significant difference for patients in complicated situations.
Special to Ophthalmology Times®
According to the World Health Organization (WHO), cataracts cause one-third of worldwide blindness, affecting about 65.2 million people, as well as moderate-to-severe vision loss in 52.6 million others, 99% of whom live in developing countries.1
With these statistics, those of us interested in “giving back” have our work cut out for us. In my case, that comes in the form of helping people with limited access to ophthalmic surgical care in less-developed areas around the world, including Kenya, Guatemala, Honduras, and the Caribbean. My most recent mission was to the island of St. Vincent, north of Trinidad and Tobago in the Caribbean.
For me, this is a familiar locale because almost every May since 2003, I have traveled there along with my family and a contingent of colleagues, including Indiana ophthalmic surgeon Eric Purdy, MD. The mission is partially supported by the Lions Club of St. Vincent and the Lions Club of Fort Wayne, IN, as well as by ophthalmic companies that donate pharmaceuticals and supplies used during the week-long mission.
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Over the years, we have established a reliable routine. We spend a day setting up a pop-up clinic and then another evaluating the surgical needs of the patients referred to us by the local ophthalmologists.
Generally, about 250 patients present for screening and approximately 80 to 100 surgeries are scheduled. We spend five days performing mostly cataract surgery, along with a few corneal cases.
When we first started going to St. Vincent, there was a handful of private ophthalmologists who referred patients to us, but there was no ophthalmologist dedicated to indigent patient care. This situation presented a problem because we had to lobby hard for the private ophthalmologists to provide follow-up care.
Today, there are four ophthalmologists who care for patients in need, including Orly Adams, MD, who was born and raised in St. Vincent and returned there to practice after being trained in Cuba and Mexico.
Dr. Adams and his colleagues perform the pre- and postoperative care, and we work with them on current medical trends in eye care as part of our educational support, which is a critically important element of the mission.
These ophthalmologists help to decrease the load of patients waiting for surgery throughout the year, but unfortunately because they do not have sufficient access to equipment or dedicated operating room time, the number of cases they can complete throughout the year is about the same as the amount we complete there in a week.
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Postoperative care is historically challenging in surgical mission work. In areas that lack good access to cataract surgery, the cataracts we remove tend to be very dense, which increases the patient’s risk of postoperative inflammation.
Typically, when our mission is complete, we simply have to hope that the patients will follow through with our instructions to apply topical steroid drops four times a day for four weeks to address that inflammation.
Often, the only access they have to postoperative medications is what we give them, so if they run out, misplace the drops, or the bottle becomes contaminated, they may not have any way to replace them. In some cases, patients may not have the ability to properly store their drops.
Confusion can also arise because we distribute several different-looking bottles, as we are relying on whatever has been donated to us for the mission.
Therefore, the local ophthalmologists who are caring for these patients in the postoperative period may have difficulty understanding exactly what regimen each patient is on, given the variability in what medications have been donated and distributed.
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Even under the best circumstances in my own practice in Florida, with routine, uncomplicated cases that are not at a high risk of inflammation, my patients often find it challenging to instill
their postoperative drops.
Some patients have difficulty physically manipulating the bottles, and others lose them, still others forget which drop to use and when.
When you add these typical compliance challenges to the storage and access issues, and further consider that there is often a language barrier, or even an inability to read the postoperative instructions in developing countries, it is easy to see that the challenges we normally face are multiplied for the patients we treat during a surgical mission.
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Having several ophthalmologists in St. Vincent to help patients in need with postoperative care represents a major step forward. Another plus was having access to dexamethasone intraocular suspension 9% (Dexycu, EyePoint Pharmaceuticals Inc.), a sustained-release drug that is applied as a single intracameral injection at the end of surgery for postoperative inflammation control.
Dexamethasone intraocular suspension 9% is a cohesive liquid steroid depot that is injected into the ciliary sulcus at the end of cataract surgery, where it delivers a tapering dose of dexamethasone for about three weeks.2
This approach alleviates patient adherence issues and the dosage errors that may be associated with topical steroid administration-a concern even in the best conditions-and still more challenging when we perform surgery on patients in developing countries.
Having a depot steroid such as dexamethasone intraocular suspension 9% is invaluable because I know with complete certainty that the patient received the dose they needed, that it was applied in the right place, at the right time, and that it would last for the necessary period of time. The fact that this is all within my control lends an irreplaceable level of security.
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Eliminating uncertainty from the postoperative care equation by providing inflammation control in the form of a depot steroid can make a significant-even revolutionary-difference for patients in compromised and complicated situations, such as those in developing countries.
All patients on our most recent trip were treated with dexamethasone intraocular suspension 9%, thanks to a donation from EyePoint Pharmaceuticals Inc.
When available, other surgeon-administered drugs that may replace standard postoperative drops, such as dexamethasone insert 0.4 mg (Dextenza, Ocular Therapeutics), phenylephrine 1%/ketorolac 0.3% intraocular solution (Omidria, Omeros), or non–FDA-approved compounded medications, could likewise be valuable in the setting of medical mission work, helping to limit the challenges of topical postoperative drug administration in the developing world.
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Mother of invention
Among the challenges that we face during these mission trips is not having all of the equipment we normally consider necessary.
For instance, during my most recent trip to St. Vincent, I had an aphakic patient with a Soemmering ring cataract that had dislocated and blocked the pupil, and it seemed the odds of having the necessary equipment to help the patient were not very good.
However, through a stroke of luck-or perhaps divine intervention-we found a +6 lens that had been left from a previous mission, I had the proper suture and several vitrectomy probes with me, and we even had a reusable vitrector that another surgeon had used earlier in the day. I was excited that I would be able to sew this lens in during what promised to be a complicated surgery.
I had already elevated the residual cataract into the anterior chamber and I had to remove the vitreous, but to my dismay, the vitrectors and vitrectomy equipment did not work, and I wasn’t sure what to try next.
At that point, one of the local ophthalmologists explained that Vannas scissors (World Precision Instruments) can be used to act like a vitrector if they are rapidly opened and closed.
With that tip, I learned a new way of approaching a problem without any of the equipment on which I typically rely. In the end, I was able to sew the lens in a perfectly round pupil that was very stable, with no vitreous in the anterior chamber and used dexamethasone intraocular suspension 9% to help control postoperative inflammation, all in a way that I wouldn’t have imagined was possible before facing this type of challenge.
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These trips show how necessity really is the mother of invention. When I encounter a difficult case and don’t have all the resources I normally would, I look at the eye and the problem from a new perspective and can sometimes come up with a solution that I can potentially apply to my patients in the United States.
Mission work in developing countries is a great reminder of the reality that exists outside my comfort zone and never fails to strengthen my surgical skills and test my resourcefulness. I always find that I return home with a greater appreciation of what it takes to be happy and productive in my own life.
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Cathleen M. McCabe, MD
Dr. McCabe is chief medical officer at The Eye Associates in Bradenton and Sarasota, FL. She is a speaker, consultant, and receives research support from EyePoint Pharmaceuticals, Inc.
SEE International. Cataracts. https://www.seeintl.org/cataracts/. Accessed January 21, 2020.
DEXYCU [package insert]. Watertown, MA: EyePoint Pharmaceuticals Inc; December 2018.