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Mitchell P. Weikert, M.D., cataract editorial board member
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Physicians are in a constant struggle to balance the quality of care we provide to our patients with the economic burden that this care places upon them. We are confronted with this challenge on a daily basis when it comes to the perioperative pharmacologic therapy that we use in cataract surgery. In addition to anesthetics, the three classes of pharmaceuticals that are routinely employed include antibiotics, steroids, and non-steroidal anti-inflammatory drugs (NSAIDs). Not that long ago, we were able to provide some of these medications at no cost to our patients. However, with changes in PhRMA guidelines and decreased sampling of medications related to off-label use, these practices have been drastically reduced. And while several truly outstanding medications have recently become commercially available, we have also seen a steady increase in the economic burden borne by our patients. As such, it is incumbent upon us to critically evaluate our therapeutic decisions to optimize cost/benefit ratios and to communicate with our patients about the risks and benefits associated with alternate therapeutic options. This month's issue of EyeWorld addresses these complicated issues by focusing on the perioperative pharmacology used in conjunction with cataract surgery. The first topic of discussion is the use of NSAIDs for the prevention of cystoid macular edema (CME). The evidence is clear that the risk of CME is lower when topical NSAIDs are used in combination with steroids versus steroids alone, whether patients are "high risk" or not. While surveys, including this issue's Monthly Pulse, have shown that approximately 80% of surgeons use NSAIDs, the pre- and post-op dosing regimens can be highly variable. Some may question their necessity given the low incidence of clinical CME. Whether you believe this or not, the idea certainly raises some worthy questions: Are they worth the added expense? Does the cost (time and money) of treating CME justify the expense of trying to prevent it? What alternate therapies are available? What are the risks of these alternate therapies? Our first cover story answers these questions and more.
The next article addresses the use of anesthesia in cataract surgery. In general, it looks like topical anesthesia "rules the roost," with retro- or peribulbar blocks reserved for more difficult cases. Injection anesthesia continues to serve a vital role in training residents, but more and more programs are transitioning their trainees to topical anesthesia at a fairly rapid pace. Upon closer observation, the choices of topical anesthetic regimens are almost as varied as the surgeons using them: gels versus drops, pre-op holding versus the OR, benzodiazepines versus propofol versus narcotics. Whatever the method, the recommendation is to work closely with your anesthesia service to create a system that individualizes the treatment for each patient. Compare your preferred methods to those discussed inside.
Even though no topical antibiotics are actually FDA-approved for infection prophylaxis in cataract surgery, they are still the primary choice for most surgeons. In fact, 95% of the Monthly Pulse survey respondents use topical antibiotic drops alone or in combination with other routes of administration. The choice of the most appropriate one should include consideration of coverage spectra, MIC levels, and resistance patterns. The use of intracameral antibiotics is definitely gaining traction following the recent ESCRS study. While many may question the original choice of cefuroxime, it's hard to argue with the clinical results. However, the question remains, "What is the preferred antibiotic choice and route to prevent post-op infections?" This is especially important in light of the increasing prevalence of methicillin-resistant Staphylococcal species. Strategies for combatting
antibiotic resistance are also addressed in this issue. We hope that you enjoy these articles and will find this information useful as you make your own decisions regarding medication use in cataract surgery.
Mitchell P. Weikert, M.D., cataract editorial board member |
