Article

As I See It

Drop-free cataract surgery: A tale of freedom

The last few times I’ve spoken to ophthalmology groups about cataract surgery, I’ve mentioned our practice’s relatively unique approach to postoperative drops — that is, we don’t prescribe them. When I conclude my talks, most questions are about just that. Since our drops policy is such a popular topic, I decided to review my own journey to it.

MY EVOLUTION

Years ago, it was common practice to prescribe postop (and sometime preop) steroid and antibiotic drops to patients undergoing cataract surgery. We surgeons had passionate debates about which types of steroid formulation and generation of antibiotic to use. Much was said about how long to use the drops and how to wean. There were always issues with compliance and occasionally issues with price.

Fast forward to recent history, when the landscape changed. The big issues became insurance and price. Many insurers wouldn’t cover the drops surgeons preferred. Even if drops were covered, some patients found themselves paying nearly as much for their medication as we surgeons were getting paid for the procedure, especially if you added a nonsteroidal drop. Add in the hours our staff spent on the phone with pharmacies and insurance providers and the cost began to affect our practices as well. I’m not even going into the subject of compliance.

So I, and many of you, tried all kinds of approaches. I tried the trans-zonular intravitreal approach with a compounded antibiotic and steroid. After a year or so, I stopped due to occasional (and sometimes nasty) hyphemas due to inadvertent ciliary body trauma, as well as a 15% iritis rebound rate. And patients didn’t like that steroid floating in their vision.

I tried intracameral injections of antibiotics and steroids into the anterior chamber but still used topical drops as a safety. About five years ago, I finally quit using the antibiotic drops and only used the topical steroids in conjunction with the intracameral antibiotics. The literature was overwhelmingly unimpressive when it came to the efficacy of antibiotic drops preventing infection, so why do it?

But I still had that steroid drop to deal with. I remembered Jim Gills telling me years ago at an Ophthalmology Management advisory board meeting that he’d been injecting steroids sub-Tenon near the equator with great success. I saw others doing something like that and decided to give it a shot.

FREE AT LAST

Here’s the routine my son and I use now. We use no preop drops, except in our surgery center the day of procedure. At the end of the operation, patients get an intracameral injection of moxifloxacin then 0.2 cc of commercially available triamcinolone, 40 mg/cc, injected inferiorly in the sub-Tenon space. No postop drops, including nonsteroidal. I’m now going on 10 years and 10,000 cases without an infection, and I’ve only seen clinically significant iritis postop in 1% of my cataract patients with this new regimen. No pressure spikes so far, even though the steroid depot can sometimes be seen in the inferior cul-de-sac for many weeks. The rates of postop CME are our lowest ever.

This is a bigger deal than some think. Some patients are over-the-moon thrilled at the thought of not buying and taking drops, so it’s certainly a win for them. But the big winner is my staff. The surgical coordinators say this has reduced their phone time by some 30%. Happy patients + happy staff = happy doctors! OM