EyeWorld Asia-Pacific December 2018 Issue

EWAP FEATURE 25 MKO Melt for cataract anesthesia by Rich Daly EyeWorld Contributing Writer AT A GLANCE • MKO Melt can be used both without starting an IV and to help start an IV. • It can prevent a preop “ramp up” of patient anxiety and allow a smoother overall experience. • The primary disadvantage is the dif culty to redose or supplement the sedation once the procedure is started. The opportunities and obstacles clinicians see in the emerging anesthesia option C inicians experi- enced with the newer anesthesia option of MKO Melt (Imprimis Pharmaceuticals, San Diego) say it has important advan- tages and some limitations. MKO Melt is a form of sublingual seda- tion for cataract and other surgery named for its medications— mi- dazolam (3 mg), ketamine HCl (25 mg), and ondansetron (2 mg). Patients place it under their tongue prior to surgery and feel the effects within a couple of min- utes. Full effect takes place around 10 minutes and lasts about 45 minutes to an hour, said Michael Greenwood, MD, Vance Thomp- son Vision, Fargo, North Dakota. “It has a nice synergy with the ketamine and the midazolam to provide analgesia,” said John Berdahl, MD, associate profes- sor of ophthalmology, University of South Dakota. “Specific to cataract surgery, patients have a tendency to look at the light more and squint less during the surgery period. The ketamine also pro- vides a mild euphoria, which from surgical experience is better for the patient.” Dr. Berdahl, who uses MKO Melt in more than 99% of his cataract patients, doses primar- ily by age with consideration of ways to plan for anxiety level and prior use of sedatives. For the vast majority of patients—including high-risk patients—he does not start an IV. However, if the patient has a very high level of anxiety, Dr. Berdahl will saline lock an IV as a backup in case it’s needed. Advantages The advantages of MKO Melt seen by Chris Bender, CRNA, in private practice, Sioux Falls, South Dakota, are that it can be used without starting an IV and to help start an IV in the case of a severe needle phobia. Because the melts are given earlier in the preop area and have a slower onset than IV medica- tions, by the time patients are transported to the operating room, they are comfortable and less able to “ramp up” their anxi- ety, which leads to a smooth over- all experience, Mr. Bender said. For Dr. Greenwood, who uses the melt for almost all of his intraocular surgeries, includ- ing cataracts, MIGS, DMEK, and refractive lens exchanges, the primary advantage is not needing to place an IV. “That saves the patient time from having to get a needle stick and also time from having to have it removed,” said Dr. Greenwood, who opted for the melt in his own phakic IOL surgery and has used it in procedures on close relatives. The patient flow benefits include allowing the staff to do other work and help the patient have an overall better experience, which reduces the chance for a delay due to waiting for an IV to be placed, Dr. Greenwood said. The MKO Melt is titratable, which allows giving one, one and a half, or two to patients depend- ing on a variety of factors. Age is one of the biggest factors affecting titration at Dr. Greenwood’s surgi- cal center. “Patients are comfortable, re- laxed, but can still follow instruc- tions if needed, such as turning their head or looking to the side during various MIGS procedures,” Dr. Greenwood said about the melt, which has a quick onset and a stable and consistent level of sedation throughout procedures. Dr. Berdahl has found patients given the melt tend to “gaze at the light and keep their eye more still at the time of surgery.” continued on page 26 December 2018