EyeWorld Asia-Pacific June 2018 issue

66 EWAP PHARMACEUTICALS June 2018 Eyes on the perioperative – from page 65 Preoperatively, she puts patients on a once-daily NSAID like Pro- lensa (bromfenac, Bausch + Lomb, Bridgewater, New Jersey) starting the day before surgery and con- tinues them on this for a month postoperatively. “NSAIDs decrease inflammation and decrease the in- cidence of CME,” Dr. Talley Rostov said. “They also help with ocular pain following surgery.” She uses a betadine prep in which a drop of betadine is placed in the eye before surgery. She also includes an antibiotic. “I do an intracameral antibiotic in- jection at the time of surgery,” she said, adding that she uses either intracameral cefuroxime or moxi- floxacin depending on whether the patient is allergic to penicillin or cephalosporin. If the patient is allergic, Dr. Talley Rostov uses moxifloxacin, which tends to be a bit more expensive. She currently has plans to move to a moxifloxa- cin dexamethasone injection at the time of surgery. “In that case, I’m going to try to use the NSAID afterward,” she said. Currently, in addition to an NSAID drop, she puts the patient on a drop of steroid. She places the patient on loteprednol twice daily for 1 month and bromfenac once daily for 1 month. Because she uses intracameral antibiotics, she does not think she needs to include a pre- or postop- erative antibiotic drop as well. Dr. Talley Rostov opts for the intraca- meral approach because of lower endophthalmitis rates found in the literature. “There are multi- ple studies that show that you decrease the incidence of endoph- thalmitis with use of intracameral antibiotics,” she said. “There was a landmark ESCRS study and a study by Shorstein et al. that showed a 22-fold decrease in the incidence of endophthalmitis following cataract surgery with intracameral antibiotics.” 3,4 While Dr. Talley Rostov currently uses an intracameral antibiotic, she is moving over to a combination moxifloxacin/dexa- methasone product. However, she will continue with the intracam- eral approach. “All the colleagues that I had who started doing that stopped,” she said. “From reports, there were a number of different issues and concerns with going a transzonular route to begin with, then there was breakthrough in- flammation.” As a result, a number of those who used this approach stopped. She decided to stay with the intracameral approach, which she liked. In diabetic patients, Dr. Talley Rostov alters her regimen some- what. She starts the patient on an NSAID 3 days beforehand and also uses an additional antibiotic drop postoperatively such as moxifloxa- cin or ofloxacin. “Also for patients who had a complicated cataract surgery or for cornea transplant patients, I put them on a topical antibiotic as well as the intracam- eral, and I use that five times a day for 2 weeks afterward,” Dr. Talley Rostov said. Nick Mamalis, MD , profes- sor of ophthalmology, John A. Moran Eye Institute, University of Utah, Salt Lake City, starts his pa- tients on preoperative drops when they come in for their surgery. In addition to standard dilating drops preoperatively, his patients receive three sets of drops of a topical fluoroquinolone antibiotic, as well as three drops of an NSAID prior to surgery. “As they’re being prepared for surgery and they’re starting an intravenous line, they’ll receive these drops preop- eratively,” Dr. Mamalis said. He does not view it as neces- sary to have these drops on board earlier. While some studies have shown that having antibiotics on board for a day or three before surgery will kill more bacteria, this is by no means the consensus, he said. “There has been an equally good number of studies that have shown that as long as antibiotics are on board before they go back to the operating room, you should get a good treatment of any sur- face bacteria,” Dr. Mamalis said. In addition, patients will receive 5% betadine as well as lidocaine gel. “It’s important that the betadine drop goes in before the lidocaine gel,” he said. Otherwise, lidocaine gel can keep the betadine from spreading out and totally covering the surface of the eye. At the conclusion of the cata- ract case, Dr. Mamalis will inject 0.1 ml of a preservative-free 0.5% moxifloxacin. “After we remove the drapes and we’re getting pa- tients ready to go out of the OR, they’ll receive a topical fourth- generation fluoroquinolone drop as well as a topical drop of a dilute betadine solution,” he said. Although he uses the intraca- meral approach, in his view it’s still important to include such postoperative drops. “I’m still hav- ing them use postoperative antibi- otic drops,” he said. “It’s like a belt and suspenders.” Currently, he has patients use a topical fourth-gener- ation fluoroquinolone drop every 2 hours the day of the surgery and four times a day for 7 days. If insurance permits, Dr. Mamalis prefers to use Vigamox (moxifloxacin, Alcon, Fort Worth, Texas) since he’s using intraca- meral moxifloxacin, which is preservative-free, but he thinks that Zymaxid (gatifloxacin 0.5%, Allergan, Dublin, Ireland) is equally good. While Dr. Mamalis currently relies on this “belt and suspend- ers” approach, he hopes new stud- ies will curtail the need for this. “We’re in the process of initiating a study to look at intracameral antibiotics and topical antibiot- ics postoperatively,” he said. “Hopefully that will give us some answers. “I also have them use a topical steroid, 1% prednisolone drop,” Dr. Mamalis said, adding that in standard cases he asks patients to use this four times a day for 2 weeks. For those who are diabetic, he will keep them on the drops longer before tapering. Finally, he will put patients on an NSAID to help prevent CME and to reestablish the blood/aque- ous barrier. The one he chooses depends on the patient’s insurance coverage. “Because I’m at a uni- versity, we get patients who don’t have a lot of insurance coverage continued on page 70