31st March 2015
No Eye Drops After Cataract Surgery—Is it Possible?
The current standard of care is steroid and antibiotic eye drops after cataract surgery to control inflammation and prevent infection. But, for some cataract patients treated at Pacific Cataract and Laser Institute, a single injection at the end of surgery takes the place of post-op drops. Patients’ lives are simplified, compliance problems go away, and the cost of medication is reduced. Will dropless cataract surgery be available on a wider scale? We are investigating the possibility.
Like most complex human activities, cataract surgery is a set of distinct and ordered steps that culminate in a specific outcome. Our desire is for that outcome to be the best it can be with minimal stress and inconvenience.
Watching cataract surgery performed by an expert surgeon and a top-notch team is fascinating. It is not necessarily the individual steps that are fascinating, but the symbiosis of operating room performers working together like an orchestra. If you have not observed the process, you owe it to yourself to take in the experience.
In the clinic, we have the privilege of seeing your patients for a pre-op visit and sometimes part of their post-op care. It is truly enjoyable to share in the visual transformation they experience. With surprising frequency, patients tell how awestruck they are by their improved vision and the level of care they have enjoyed.
As you know, cataract patients typically use antibiotic and steroid eye drops after surgery to control inflammation and prevent infection. These medications are very effective, but downsides include cost, compliance and the inconvenience of using multiple drops several times a day.
Could we further improve the surgery experience by reducing or eliminating the need for post-op eye drops? Developments in pharmaceutical technology are making this a possibility.
Dropless Cataract Surgery
For several months, we have been investigating the use of Tri-Moxi (Imprimis Pharmaceuticals)—a new proprietary compounded drug that combines the anti-inflammatory triamcinolone with the antibiotic moxifloxacin. The dropless option is explained to some patients. For those who choose it, Tri-Moxi is injected into the vitreous at the end of cataract surgery. Through our careful approach, we are gathering data on the pros and cons of this option.
At the conclusion of cataract surgery, a small volume of Tri-Moxi is injected into the anterior vitreous. Tri-Moxi can be delivered via a tranzonular approach with a bent tip cannula or through a pars-plana injection. The procedure adds about 30 seconds to the typical cataract surgery. You can watch a brief animation below:
Having the medicine placed in the eye by the surgeon is certainly more convenient and less costly than eye drops. Advantages of Tri-Moxi include:
- No medicated drops required in 95% of cases
- Simplified post-op regimen
- Reduced compliance problems
- Reduced risk of eye drop application problems
- No prescriptions for patients to fill
- Reduced cost overall
Cataract surgeons with extensive Tri-Moxi experience report that only 5% of patients require more anti-inflammatory than the drug combination provides.
We all know that post-op eye drop compliance is a major problem, and poor adherence to after-surgery instructions is common. How many patients have you seen with persistent inflammation after cataract surgery who claim to have been diligent with their drops? Patients do not want to disappoint us, so many do not admit less-than-perfect adherence.
Individuals with arthritis and other mobility problems may do their best to follow instructions but have difficulty with safe and adequate drop instillation. With Tri-Moxi, safe instillation, compliance and adherence to instructions are not required.
When we prescribe post-op eye drops, some pharmaceutical plans deny a second set for the fellow eye. Patients are inconvenienced and our clinical staff frequently has to call to try to get the second set of drops covered. And almost every day we hear patients complain about the cost of post-op drops. The price of generic medications has increased substantially, in many cases achieving parity with brand-name options. Patients routinely pay upwards of $100 per eye, and substantially more if the latest generation of antibiotics and anti-inflammatory are prescribed. For those on fixed incomes, this can be a major budget breaker.
Tri-Moxi is considerably less expensive than eye drops. However, as Medicare and private insurance carriers do not currently pay for this novel medication, ways need to be developed for carriers to either cover the cost or allow patients to pay.
The biggest disadvantage we have seen so far with Tri-Moxi is that patients experience cloudy vision and floaters for a few days after cataract surgery. This is due to the opaque nature of the drug combination. The transient loss of pristine red reflex can be disconcerting the first time you see it. However, within one to two days, the injected medicine is usually settled into the inferior vitreous and good vision has returned. Patients who want or need speedier return of good vision may prefer eye drops.
If the lens is unstable, the injection could compound the problem. It is also theoretically possible that a patient could have steroid induced intraocular pressure increase. However, this has not been observed by surgeons experienced with Tri-Moxi.
Tri-Moxi should be avoided with several types of patients:
- Those who have had previous vitrectomy
- Those with unstable lenses
- Known steroid responders
- Those who need or wish to return to their best vision as soon as possible
Our early experience with dropless cataract surgery has been favorable. However, as with any new technique or procedure, there may be problems that only become apparent weeks or months later, so we are proceeding carefully and conservatively. While our initial exposure suggests that Tri-Moxi offers excellent corticosteroid and antibiotic coverage with several important benefits to patients, our surgeons want to gain more experience before offering this option on a wider scale.
Call with Questions
If one of your referred patients is offered and elects dropless cataract surgery, it will be noted in our post-op communication to you. If you have questions about Tri-Moxi, or wish to discuss a specific case, always feel free to call any of our optometric physicians.