September 2018

RETINA

Research highlight
Stacking up steroids


by Maxine Lipner EyeWorld Senior Contributing Writer


In helping to keep CME, pictured here, at bay, prednisolone and dexamethasone were found to be equally effective.
Source: Brandon Baartman, MD

 

Comparing post-cataract prophylactic results

For preventing pseudophakic cystoid macular edema (CME) after routine cataract surgery, prednisolone and dexamethasone are equally effective, according to Brandon Baartman, MD, Vance Thompson Vision, Omaha, Nebraska. A study published in the Canadian Journal of Ophthalmology1 sought to compare the two to determine whether any efficacy was lost in facilities that opted to use one of these on an ongoing basis.
The Cleveland Clinic, where Dr. Baartman was then practicing, sought to unify the postoperative regimen across different sites, with an eye toward reducing cost. “However, we weren’t sure if we were sacrificing results for the benefit
of saving a dollar,” Dr. Baartman said. “We wanted to know if we could expect equivalent outcomes with either medication and therefore feel good about choosing the one that was more cost-conscious for the health system as a whole.” At the time, dexamethasone was almost five times less expensive than prednisolone.

Evaluating CME incidence

Included in the retrospective chart review were 1,135 patients whose electronic medical records indicated they had been placed on either of the two steroids following cataract extraction over a 6-month period and who had the requisite 12 months of follow-up, Dr. Baartman noted, adding that anyone with significant comorbidities or risk factors for CME were excluded. In the investigation, 721 patients were treated with prednisolone acetate and 414 were treated with dexamethasone.
“The study gave us a good idea of our incidence of CME after cataract surgery in this otherwise low-risk population, which tended to be about 4%,” Dr. Baartman said. “It was a little higher than what I was anticipating, but certainly lower than many of the other published studies that use different methods for the diagnosis of CME.”
Investigators determined that there were no significant differences in CME rates with prednisolone, which had a 4% rate, or dexamethasone at 4.1%. Dr. Baartman was surprised that there was so little difference in incidence. “If you survey among surgeons, the general thought is prednisolone tends to be more efficacious for intraocular inflammation due to potentially higher potency or increased aqueous absorption of concentrations in aqueous after topical administration,” he said. “But what we found was that both performed similarly in the clinical setting, at least for routine cataract surgery.”

Considering cost

Dr. Baartman stressed that this helps practitioners better contextualize the decisions that they make in selecting a steroid. “For something like cataract surgery, which on an annual basis is one of the most commonly performed procedures in the U.S., I think that this can be important for providers to understand,” he said, adding that there can be a secondary cost to a health system in opting for a cheaper medication that may result in unforeseen complications. But once the determination has been made that efficacy is equivalent, practitioners can more effectively bring cost into the equation.
However, the cataract steroid issue is still not totally resolved. Many formulations of the steroids come in combination with other medications that practitioners might want to use after cataract surgery, Dr. Baartman explained. For example, Tobradex (Alcon, Fort Worth, Texas) combines the antibiotic tobramycin with the steroid dexamethasone. There are also formulations of prednisolone with the fluoroquinolone gatifloxacin and the NSAID bromfenac, he added. Based on the availability of such combination agents, it may make it possible to add value by simplifying the patient’s drop regimen. “I think you reduce drop burdens by combining them,” Dr. Baartman said. “If there is one that includes an antibiotic and a nonsteroidal, you can reduce how many drops a patient has to use after surgery.”
While investigators did not study either prednisolone or dexamethasone in combination with any other agents, a synergistic effect with NSAIDs has been previously noted, Dr. Baartman pointed out. “There may be a need for understanding if one [steroid] happens to be more synergistic with NSAIDs than the other, which might sway one’s decision here.”
In general, on a larger scale, practitioners need to be inquiring in their own practices about the rates of various components of cataract surgery and trying to determine if there is a cost-saving alternative, Dr. Baartman said. “But if there’s an effective alternative that may save costs up front, we also want to make sure that we’re not sacrificing patient care quality in turn for saving a dollar,” he said. “Although I know there are emerging therapies such as injectables and implants to help reduce the incidence of CME after cataract surgery, I hope that in scenarios where practitioners are still choosing among various monotherapies, this study might help provide some guidance.”

Reference

1. Baartman BJ, et al. Prednisolone versus dexamethasone for prevention of pseudophakic cystoid macular edema. Can J Ophthalmol. 2018;53:131–134.

Editors’ note: Dr. Baartman has no financial interests related to his comments.

Contact information

Baartman
: Brandon.baartman@vancethompsonvision.com

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