NO MORE DROPS In dropless cataract surgery, most patients no longer need to take drops before or after surgery.

Traditional cataract surgery requires the patient to use multiple eye drops before and after surgery, often up to 4 times a day for a month or more. In most cases, dropless cataract surgery eliminates the need to apply more than 400 drops in patients who are having cataract surgery on both eyes.

In dropless cataract surgery, surgeons place a compounded intraoperative anti-inflammatory/antibiotic injection in the eye at the time of surgery. The medication is absorbed by the eye over the next month, providing patients the benefit of antibiotics and anti-inflammatories without needing drops.

Dropless surgery ensures patients get the post-op medications they need without having to comply with a complicated regimen, says Tracy A. Rhodes, RN, BSN, director of nursing at The Eye Center of North Florida in Panama City. "The hardest part of surgery was getting patients to comply with their drop schedule," she says. "Some take diligent notes but still get confused, others just shrug it off as too complicated."

Typically patients receive 3 drops post-operatively: an anti-inflammatory, a steroid and an antibiotic. "An average patient would get a minimum of 3 antibiotic drops, 3 anti-inflammatory drops and 4 steroid drops per day," says Ms. Rhodes. "The antibiotic drops would end after a week, the anti-inflammatory continued for 3 weeks, and the steroids tapered off. That's an incredible amount of stuff to keep up with. And keep in mind that we typically would do the other eye after 2 weeks, so the process would overlap. Patients didn't know what to do."

Instead, in dropless surgery, surgeons inject a solution containing the medications patients need post-operatively into the eye's anterior chamber before closing, eliminating the need for post-op drops. While some claim it reduces the risk of infection, evidence is limited due to cataract surgery's already-low infection rate, says Ms. Rhodes. Rather, the biggest benefit is improved patient compliance. "Anytime compliance is higher, the surgeons will be more satisfied," she says, "and so will the patients."

Fewer drops, happier patients
While most patients don't receive drops after the dropless procedure, there can be times when it's necessary, says Bret L. Fisher, MD, medical director of the Eye Center of North Florida. "The vast majority of our patients are completely dropless," he says. "Some patients who are at increased risk of macular edema — or if they had it, it would be very detrimental — get 1 anti-inflammatory drop 1 time a day for a few weeks. Typically these are patients who are diabetic or have a multi-focal lens implanted.

"About 10% of patients will get some breakthrough inflammation about 1 week post-op, too," he adds. "They also get a single non-steroidal anti-inflammatory drop."

Ms. Rhodes notes that each surgeon has tinkered with the dropless surgery a bit, with several now prescribing a single anti-inflammatory post-op drop to all patients for some extra insurance. "We started out doing virtually no drops in patients," she says. "But some surgeons found that they liked to have a little extra anti-inflammatory medicine in the mix. So instead of an antibiotic twice a day, an anti-inflammatory 3 times a day and steroids 4 times a day, they just have to put 1 drop in before bed."

Simplifying, or eliminating, post-op drops isn't the only reason to make the switch, says Ms. Rhodes. She notes that since each injection comes as a single-dose, patient-prescribed amount, it helps limit any cross-contamination risk.

OCULAR PHARMACEUTICALS
3 New Combination Drugs Simplifying Ophthalmic Surgery

STREAMLINED When it comes to new pharmaceuticals for ophthalmic procedures, simplicity is the name of the game.

Dropless surgery isn't the only new pharmaceutical that's simplifying ophthalmic surgery. Here are 3 new combination medications that make cataract and other refractive surgery easier, quicker and more efficient.

• A simple pre-op drop regimen. Previously, nurses had to drown patients with drop after drop to numb the eye, dilate the pupil, and prevent post-op infections and inflammation before surgery, says Tracy A. Rhodes, RN, BSN, director of nursing at The Eye Center of North Florida in Panama City. Her center orders a "combo drop" from the center's compounding pharmacy. The combination drop includes an antibiotic, an anti-inflammatory, 2 dilating agents and a numbing agent. "Instead of a nurse having to put 3 to 4 drops in 3 times for each patient before surgery, you only do 1 drop," she says.
• Better pupil dilation and pain control. Combination drugs also play a role in intraoperative solutions. T. Hunter Newsom, MD, founder of the Newsom Eye & Laser Center in Tampa, Fla., points to a new solution used during cataract surgery to enhance pupil dilation and ward off post-op inflammation and pain. The solution combines the dilator phenylephrine with the anti-inflammatory ketorolac, and is mixed with the doc's irrigation solution to provide a steady stream of the medications during surgery. While doctors have been adding pupil dilation drugs to irrigation solutions for years, Dr. Newsom notes that the new formula is the first combination that's FDA-approved specifically for this use. "We have been using epinephrine in our irrigating bottle to keep pupils dilated during surgery for a long time," says Dr. Newsom. "We also use NSAIDs pre-operatively for 3 days to help get patients dilated more and faster for cataract surgery."
• An alternative to dropless surgery. Cataract patients who don't want dropless therapy — or whose surgeon doesn't perform the procedure — can receive a single combination drop that includes a steroid, an antibiotic and an anti-inflammatory (prednisolone acetate, moxifloxacin hydrochloride and ketorolac tromethamine, respectively), says Bret L. Fisher, MD, medical director of The Eye Center of North Florida. Those undergoing LASIK or photorefractive keratectomy receive a combination of a steroid and an antibiotic. Patients are instructed to use the single drop 3 times a day for 1 to 3 weeks, depending on the surgery. Compared to standard post-op regimens, patients love the single drop's simplicity, he says. That's especially true since the center purchases and distributes the drops to patients as part of their surgery. For example, LASIK patients pay a bundled fee that includes the cost of the combination drop, which they then receive at the center once their surgery is complete. "That way we know they received the drops and that they know exactly how to use them," says Dr. Fisher. "It ends up helping us ensure compliance, and it works out great for our patients."

— Kendal Gapinski

While many facilities, surgeons and patients sing the praises of dropless surgery, there are a few things to consider before adding it to your cases. First is its cost. Ms. Rhodes notes that while it saves patients nearly $400 in post-op drops, the facility must absorb the added cost-per-case for the injections, which is around $20. "All of our patients get it, whether they're upgrading their surgery or if it's just a standard procedure," she adds.

"We talked to our consultants and realized that it wasn't a cost that we could pass along to the patient, so we absorb the added cost of the dropless surgery," says Dr. Fisher. "But we consider it a marketing expense. The word of mouth has been so fabulous that it's resulted in patients seeking us out."

Plus, fewer phone calls from confused patients means a more efficiently run center. "It cut down on staff spending time returning calls from patients and calling pharmacies to make sure patients picked up their drops," he adds. "There's an economic benefit there, too."

Patients will experience some blurriness and floaters after surgery, notes Ms. Rhodes, so she suggests warning patients about this ahead of time to minimize any surprise. "We just make sure to tell them that they'll see 'webs' or 'spiders' in their eye, but once the medicine is absorbed it will go away," she says. "It's a tradeoff. But most prefer the floaters to $400 in post-op drops." OSM