EyeWorld Asia-Pacific June 2018 issue

65 EWAP PHARMACEUTICALS June 2018 Eyes on the perioperative drug delivery prize by Maxine Lipner EyeWorld Senior Contributing Writer Platforms cataract practitioners are using W hile all practitioners offer their patients some form of drug coverage around the time of cataract surgery, the approach can vary significantly. For some, the idea is to only deliver medication during the procedure with an injection, while for others such injections are paired with a full complement of drops. EyeWorld asked leading practitioners to share their recommendations. Neal Shorstein, MD , associ- ate chief of quality, Kaiser Perma- nente, Walnut Creek, California, takes the former approach. He prescribes just a dilating drop for the patient to instill preoperatively on the day of surgery. “Patients instill it in their own eye,” he said. “That’s the only perioperative drop.” Dr. Shorstein doesn’t prescribe any antibiotic, NSAID, or steroid drops at this point. “The antibiotic is an intracameral injection at the time of surgery, and that takes care of their prophylaxis for endoph- thalmitis,” he said. “Our studies have shown that the intracameral injection is superior to any drops and that drops don’t add anything on top of intracameral injection.” Intracamerally, his first line drug is 1,000 milligrams of cefuro- xime, while his second line drug is injecting 0.3–0.4 milliliters of 0.1% moxifloxacin. The approach has been successful for keeping en- dophthalmitis at bay. “We’ve had no complications, and we found in Northern California Kaiser Perma- nente that our rate of endophthal- mitis has gone down by about 4- to 5-fold using intracameral,” he said. For inflammation and macular edema prophylaxis, Dr. Shorstein subconjunctivally injects triam- cinolone during the procedure. “I have been doing this for 8 or 9 years based on some studies,” he said, adding that these showed that the injection of steroid was equivalent to the administration of topical steroid. Dr. Shorstein did his own study that showed a low rate of CME using any prophy- laxis regimen, whether it included NSAIDs or not. 1 “We showed that adding NSAIDs to steroid did lower the rate of CME a little more, but it was lowering it from an already small rate to an even smaller rate, so it was a marginal decrease in CME,” he said. “If CME does occur, it is readily treatable.” Postoperatively, with this regimen, he finds that there is no need to put patients on any drops. “They have a visible depot for 4–6 weeks, and that’s the slowly eluting triamcinolone,” Dr. Shorstein said. Triamcinolone is highly effec- tive against CME, he thinks. Dr. Shorstein cited the Prevention of Macular Edema after Cataract Sur- gery study in which 213 diabetic patients were randomized into one of four groups. 2 All patients received a steroid and an NSAID drop. The control group received no injection, another group ad- ditionally received a 40-milligram subconjunctival triamcinolone injection, the third group received Avastin (bevacizumab, Genentech, South San Francisco), and the final group received triamcinolone plus Avastin. “They found an 8% incidence of visually significant CME in the control group,” Dr. Shorstein said, adding that the group that received the drops plus the triamcinolone injection had a rate of visually significant CME of zero. The Avastin was not found to be helpful here, he noted. “I think the triamcinolone injection far outweighs any steroid or NSAID in effect,” he said. Audrey Talley Rostov, MD , director of cornea, cataract and refractive surgery, Northwest Eye Surgeons, Seattle, includes some drops pre- and postoperatively. Progerssion of eye in which subconjunctival triamcinolone was used. Source: Neal Shorstein, MD continued on page 66