The economics of going ‘dropless’


The economics of going ‘dropless’

Prophylactic injections can save hassle and money for both you and your patients.

By Cynthia Matossian, MD

Our practice is currently under a barrage of phone calls from confused patients seeking guidance concerning insurance coverage for their perioperative cataract surgery eye drops.

The problem is that pharmacists often swap out prescribed branded medications for generics without contacting the prescribing physician. In some cases, these generics are dramatically different. Patients have no clue the medication covered by their insurance requires a different instillation schedule. This leads to errors with potential under-treatment and possible post-operative complications.

I believe the aggravation this conundrum causes can be alleviated with prophylactic intra-operative injections. That’s why we’re currently engaged in a clinical trial with trans-zonular injections of Tri-Moxi or Tri-Moxi-Vanc (Imprimis Pharmaceuticals, San Diego, Calif.). These injections are designed to reduce the need for postoperative medications. Delivering these injections could ultimately reduce practice costs by reducing the onslaught of phone calls and by taking patient compliance issues out of the equation.


The injectable suspension is deposited trans-zonularly into the anterior vitreous behind the capsular bag with a 30 gauge cannula after the IOL is in place. Irrigation and aspiration is then performed to remove the viscoelastic. Stromal hydration is completed per usual to close the incision.

With these injections, patients should rarely need topical antibiotics and steroids. Once a day topical NSAIDs can still be used. Moreover, the patients will no longer need extensive technician time with complicated post-operative medication schedules.


Tri-Moxi is $20 and Tri-Moxi-Vanc is $25 per injection. Compare that to the $100-$200 patients would be shelling out for each of the three eye drops. The issue, however, is that some insurances don’t currently cover Dropless therapy (Medicare may, through either a local policy decision or ABN). In other words, until policies are established either you or your ASC may have to absorb the cost. That’s the tradeoff. In exchange, you receive greater staff productivity, fewer phone calls and fewer noncompliance issues.


This trans-zonular application of three well-known medications is relatively new. We do not have established protocols for their use. Some surgeons are using this product with every cataract patient, whereas others are limiting it to those who may be a little confused or unable to instill drops in their eyes due to comorbidities such as a stroke or Parkinson’s.

For now, prophylactic injections are in their infancy, but they’re poised to make a significant impact on our practice patterns in the years to come. OM

Cynthia Matossian, MD, FACS, is the founder of Matossian Eye Associates. Her e-mail is