November 2018


Pharmaceutical focus
Dropping drops?

by Ellen Stodola EyeWorld Senior Staff Writer/Digital Editor

Injection of dexamethasone/
ketorolac into the anterior chamber after cataract surgery
Source: John Berdahl, MD

Cataract surgeons weighing use of less topical medication

Some practitioners today have moved away from having patients use a plethora of drops for cataract surgery to other approaches that minimize or even look to do away with these altogether. EyeWorld asked several leading ophthalmologists about their current regimens.
John Berdahl, MD, associate professor of ophthalmology, University of South Dakota Medical School, relies on a combination medication preoperatively and postoperatively, which includes Pred-Gati-Brom (prednisolone acetate/gatifloxacin/bromfenac, Imprimis, San Diego) once a day for 3 days before cataract removal and once a day for a month after surgery. During the procedure, he injects a small amount of Dex-Moxi-Ketor (dexamethasone/moxifloxacin/ketorolac, Imprimis) subconjunctivally into the anterior chamber. “Patients get an intracameral steroid, antibiotic, and NSAID at the time of surgery and they get a once-a-day drop for a month,” Dr. Berdahl said.
In his view, the benefits of the approach are great, with data indicating that intraocular antibiotics lower the rate of endophthalmitis. He finds that with a steroid inside the eye the corneas look better on postoperative day 1. While one of the concerns of using an intraocular steroid is that there may be an IOP spike, Dr. Berdahl has not found this.1 “We studied that carefully in glaucoma patients who had stents placed and we didn’t find any increase in IOP spikes,” he said.
In addition to the steroid effect of clearing the cornea and the antibiotic protection, the NSAID plays a role, according to Dr. Berdahl. “We think that NSAIDs help with comfort and preventing CME postoperatively,” he said.
While Dr. Berdahl thinks that it would be reasonable to take an entirely dropless approach, relying strictly on intraocular antibiotics didn’t seem practical in his practice. “Because we practice in a rural setting where sometimes it’s hard for patients to get back to us, we think having a once-a-day drop to help prevent rebound inflammation is helpful,” he said. “But I wouldn’t say that it’s wrong to do a totally dropless approach.”
His current regimen has evolved from one he used just 3 or 4 years ago when he started using intracameral antibiotics and was injecting into the vitreous at the time. The regimen then included vancomycin, moxifloxacin, and triamcinolone, he explained. “It worked well but we would have floaters and we would disturb the vitreous body,” Dr. Berdahl said. “Now we inject into the anterior chamber and there are no floaters, so we think that this is a more patient-centric approach, while still accomplishing the goal of delivering intraocular medication.”
The regimen also no longer includes vancomycin, which Dr. Berdahl stopped using because of concerns over hemorrhagic occlusive retinal vasculitis (HORV). “It does appear that it is linked,” he said. Dr. Berdahl, though watchful for TASS, is more confident about using the intraocular injection approach due to the fact that Imprimis is a reputable 503B compounding pharmacy. “We’ve done 10,000 of these injections and haven’t had a TASS outbreak or an issue with it,” he said. “I think there is risk, but it’s tiny.”
P. Dee Stephenson, MD, associate professor of ophthalmology, University of South Florida College of Medicine, Tampa, Florida, usually relies on drops. “About 3 days before surgery, patients are on Besivance BID [besifloxacin, Bausch + Lomb, Bridgewater, New Jersey], BromSite BID [bromfenac, Sun Pharma, Mumbai, India], and Lotemax [loteprednol, Bausch + Lomb],” she said. “Intraoperatively, I still use vancomycin in the bottle,” she said, stressing that she’s never had any issue occur with it. Postoperatively, her regimen includes Besivance twice a day for 2 weeks, BromSite twice a day for 6 weeks, and Lotemax four times a day for 1 week, tapered by giving one drop less over the next 6 weeks.
In patients for whom cost is a concern, Dr. Stephenson will prescribe a compounded Imprimis drop of all three medications in the same bottle. In certain high-risk cases, such as someone with advanced glaucoma or uveitis, she will give patients moxifloxacin intracamerally. Some who have insurance that covers their topical drops prefer to use this. “A lot of older patients, if they have to pay $90 and their copay is $20, they’re not going to do it if it doesn’t go toward their deductible, medication, or anything,” she said.
She doesn’t typically use injections for several reasons. “I do a lot of accommodative lenses and I don’t like doing a blind stick and sticking medicine inside the eye because it increases the volume and I’m not sure where that lens would go,” Dr. Stephenson said.
When it comes to HORV, Dr. Stephenson acknowledged that this is a terrible retinal issue, but said she thinks there may be some extenuating circumstances with regard to vancomycin. “I spoke to several retina doctors and one who I have worked with for the last 30 years has used it forever and has never had a problem,” she said. “If you put vancomycin in the bottle, that’s the first medicine for endophthalmitis that they’re going to inject intracamerally anyway, so I’m concerned but not worried about HORV.”
Nick Mamalis, MD, professor of ophthalmology, Moran Eye Center, University of Utah, Salt Lake City, doesn’t start his patients on drops prior to their arriving at his center. “I found that there were some issues with confusion and compliance,” Dr. Mamalis said. Prior to surgery, patients get three sets of a fourth generation fluoroquinolone, such as moxifloxacin or gatifloxacin, as well as three sets of a topical NSAID, such as ketorolac, Dr. Mamalis noted. He likes to have the NSAID on board when starting surgery since there’s the possibility that it can decrease some of the blood aqueous breakdown that occurs normally during cataract surgery, he explained.
At the conclusion of the case, Dr. Mamalis injects 0.1 cc of preservative-free moxifloxacin intracamerally into the anterior chamber, which he thinks helps prevent endophthalmitis. “There’s good evidence from multiple studies both in Europe and the U.S. that intracameral antibiotics show a significant decrease in the risk of postoperative endophthalmitis,”2 Dr. Mamalis said. In addition, postoperatively, he still has patients use a fourth generation fluoroquinolone for 7 days. Dr. Mamalis terms this the “belt and suspenders” approach to guarding against endophthalmitis.
“Also, postoperatively they’ll have the usual prednisolone four times a day for at least 2 weeks with a taper and a topical NSAID four times a day with a taper,” Dr. Mamalis said. “There has been evidence through the years that using a combination of NSAID and steroid not only helps to calm the postoperative inflammation but also helps to decrease the risk of postoperative CME following cataract surgery.” The PREMED study has shown that the combination of steroid and NSAID is superior to just steroid or just NSAID in the prevention of CME, he said.
While in theory the idea of totally dropless cataract surgery appeals to Dr. Mamalis, in practice he thinks that it has a long way to go. “Anything that we could do that would decrease potential problems with compliance issues is going to be an advantage because we still have patients who when we give them the drops just don’t use them,” he said. But the main issue currently is that there is still no approved medication for doing this, he stressed, adding that this means using compounding pharmacies and that there have been some issues with those. “In Texas, there was an outbreak of patients who had severe posterior segment inflammation following problems with how the medications were compounded,” Dr. Mamalis said. “It would be ideal if we had an FDA-approved medication that could be put together in ways that we know what we’re getting, but this doesn’t exist at the moment.”


1. Ferguson TJ, et al. Evaluation of a trabecular micro-bypass stent in pseudophakic patients with open-angle glaucoma. J Glaucoma. 2016;25:896–900.
2. Haripriya A, Chang DF. Intracameral antibiotics during cataract surgery: evidence and barriers. Curr Opin Ophthalmol. 2018; 29:33–39.

Editors’ note: Dr. Berdahl has financial affiliations with Alcon (Fort Worth, Texas), Allergan (Dublin, Ireland), Bausch + Lomb, and Imprimis. Dr. Mamalis and Dr. Stephenson have no financial interests related to their comments.

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