EyeWorld India March 2021 Issue

FEATURE 12 EWAP MAR C H 2021 by Liz Hillman Editorial Co-Director Cataract postop regimens examined C ataract surgery anti-inflammatory regimens have changed significantly in the last decade, with an emphasis on improving patient compliance. “It has changed considerably; it’s changed in nuanced form and substance,” said Michael Saidel, MD “It’s changed in how we administer medications and which ones are available to us.” Dr. Saidel said older forms of NSAIDs—ketorolac, diclofenac— have fallen away in his practice in favor of newer generation ones like bromfenac and nepafenac. He said he starts a patient on an NSAID 2 days preop and has them continue for several weeks postop. “The big change has not been the drugs themselves but rather how I administer them,” Dr. Saidel said. While topical has always been the most common, he said he’s now often using Dexycu (dexamethasone intraocular suspension 9%, EyePoint Pharmaceuticals) in many patients. “I think it’s better to put the oil in the engine as opposed to pouring it on the engine,” he offered as an analogy. Dr. Saidel said his use of corticosteroids has also evolved. He now uses a combination prednisolone/nepafenac/ moxifloxacin instead of three different drops. He begins this 2 days preop and continues for a few weeks postop with standard TID dosing, no taper. For Michael Savetsky, MD, changes in NSAID use over the past decade have been Contact information Saidel: msaidel@yahoo.com Savetsky: msavetmd@gmail.com Walter: kwalter@wakehealth.edu Whitman: whitman@keywhitman.com This article originally appeared in the December 2020 issue of EyeWorld . It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. in frequency with a focus on patient compliance. When he started residency in 2008, he said three different eye drops—a steroid, antibiotic, and anti- inflammatory 4 times a day— were prescribed to cataract patients. “As time went on, drug companies started coming out with new iterations of drops that you can use less frequently,” Dr. Savetsky said. “The biggest change started when doctors were attempting to go dropless, and that’s where we are right now.” “In one surgery center, I’ve been injecting … moxifloxacin and Dexycu. Then [the patient goes] on an NSAID for 4 weeks once a day,” Dr. Savetsky said. “We have to confirm that insurance will cover the Dexycu, but it’s been convenient for patients when it goes through. At the other surgery center, I don’t have access to the moxifloxacin, so I will inject Dexycu—for those patients who are covered—and afterward the patient will take antibiotic and NSAID drops.” Dr. Savetsky added that if there is a complication or if he anticipates more inflammation, he might put the patient on a steroid drop as well. Conversely, if the patient was a known steroid responder or had advanced glaucoma, he said he might not inject Dexycu. Jeffrey Whitman, MD, said he injects a steroid and antibiotic into the vitreous or anterior chamber in about 40% of his patients. These include ones who he thinks might be more prone to inflammation, such as those with a history of iritis or uveitis, patients of African American or Hispanic descent who might have cell and flare longer, or those with a dense cataract where more ultrasound time might be required. Dr. Whitman said he’s also using Dexycu more regularly now and noted that in 100+ cases, none have needed to use an additional steroid drop as a “rescue.” One downside to this option at the moment, Dr. Whitman said, is that despite its current pass-through status, some insurers are not accepting it, creating more work for the billing staff. Dr. Whitman also said his staff is looking at the rescue rate of Dexycu compared to Dextenza (dexamethasone ophthalmic insert 0.4 mg, Ocular Therapeutix). “We’d like to use whatever is most successful in the eye. Also, all of these are steroids, not antibiotics, so you have to put the patient on an antibiotic as well,” he noted. What hasn’t changed over the years are the reasons for using an NSAID. However, Dexycu in the posterior chamber Source: Michael Savetsky, MD