July 2019

CATARACT

Pharmaceutical Focus
Using steroids for cataract surgery


by Maxine Lipner EyeWorld Senior Contributing Writer

“There’s a significant number of patients who I think will have quicker recovery and less irritation and pain by also utilizing steroids.”
—David Hardten, MD


Cataract surgery today is usually topped off with a steroid, but there are myriad approaches. EyeWorld asked several leading ophthalmologists to share their steroid regimens.
David Hardten, MD, typically utilizes prednisolone acetate drops in combination with an NSAID. “There’s a significant number of patients who I think will have quicker recovery and less irritation and pain by also utilizing steroids,” he said. He usually places patients on a steroid four times a day for 1 week and then two times a day until the bottle runs out. However, in cases where there is a lot of inflammation after the surgery, when the patient has the second eye done, Dr. Hardten may either prescribe a higher concentration or recommend taking the medication more frequently.
If the patient experiences a pressure spike, Dr. Hardten may lower the frequency of the steroid dosing or select another medication. However, in the rare case where the pressure is extremely high, Dr. Hardten would add a medication to lower it.
In some high-risk patients with a history of CME in the other eye or who are receiving VEGF injections for diabetic macular edema, Dr. Hardten may give a subconjunctival injection of triamcinolone acetonide. Typically, he prefers not to use this approach because of the discomfort of the injection as well as concerns that the medication cannot be removed if there is a pressure spike. In cases where he uses triamcinolone acetonide, the patient is also placed on standard postoperative drops or possibly on an accelerated topical steroid regimen.
Kevin M. Miller, MD, usually prescribes prednisolone acetate 1% drops four times a day for 4 weeks. Some exceptions to his typical post-cataract steroid regimen include cases of HLA-B27 uveitis and juvenile rheumatoid arthritis. He puts such patients on steroid drops a week before surgery four times a day and then after surgery every 2 hours while awake to keep inflammation in check. He prescribes NSAIDs only for eyes that are at high risk for developing postoperative cystoid macular edema, which is about 2% of the population.
The literature indicates that about one in three patients is sensitive to prolonged steroid use and will experience a pressure spike, Dr. Miller said. Young myopes have a higher susceptibility and must be monitored more closely. At the 2-week postoperative mark, he finds that a small number of patients—usually those who have pre-existing glaucoma—will have a pressure issue. Even with the risk of a pressure rise, it’s more important to control inflammation and make sure patients don’t develop macular edema since glaucoma drops can always be added to the regimen to control pressure, he stressed. His go-to glaucoma drop is dorzolamide/timolol.
“In general, the more potent the steroid, the more it will penetrate the eye and the higher the risk of a pressure spike,” Dr. Miller said, adding that difluprednate would have the greatest risk and fluorometholone the least. Dr. Miller does not currently inject steroids, citing that while there is plenty of good literature to support the injection of antibiotics, the same is not yet true for steroids. “If you have a pressure spike after you inject a corticosteroid, it’s much harder to deal with because you have to wait for the steroid to go away from inside the eye,” he said.
Deepinder K. Dhaliwal, MD, also uses prednisolone acetate 1%, advising patients to take it every couple of hours the day of surgery and then four times a day for 1 week. She tapers this by 1 drop for the next 3 weeks. “When I operate on patients who have retinitis pigmentosa or diabetic macular edema, I might use the steroid longer,” she said. With prednisolone, she always educates patients about the importance of vigorously shaking the bottle since this is a suspension, not a solution. If they’re still inflamed despite using prednisolone, she’ll switch them to either the branded Pred Forte (Allergan) or Durezol (difluprednate, Novartis).
She finds she rarely encounters problems with pressure spikes, adding, however, that these are more likely to arise with use of difluprednate, which she doesn’t typically use unless there is a history of uveitis. In the rare instances that she encounters a pressure spike, she switches the patient to a milder steroid, if possible, and may add a glaucoma drop to control pressure.
In select cases where her retinal colleagues recommend it, such as those involving pre-existing CME, she does an intravitreal injection using triamcinolone acetonide.
Dr. Dhaliwal is hoping to soon use newly FDA-approved options such as Dextenza (Ocular Therapeutix), a hydrogel plug that elutes dexamethasone after cataract surgery, and intracameral, single injection Dexycu (dexamethasone, EyePoint Pharmaceuticals), which is longer lasting than triamcinolone, she noted. “I have not had the opportunity to use either one, but the future is bright because we can take the patient compliance out of the equation,” she said.

About the doctors

Deepinder K. Dhaliwal, MD
Professor of ophthalmology
University of Pittsburgh School
of Medicine Pittsburgh

David Hardten, MD
Minnesota Eye Consultants
Minneapolis

Kevin M. Miller, MD
Kolokotrones Chair in Ophthalmology
David Geffen School of
Medicine at UCLA
Los Angeles

Financial interests

Dhaliwal: Ocular Therapeutix
Hardten: None
Miller: None

Contact information

Dhaliwal: dhaliwaldk@upmc.edu
Hardten: drhardten@mneye.com
Miller: miller@jsei.ucla.edu

Using steroids for cataract surgery Using steroids for cataract surgery
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