In cataract surgery, there’s a drug for that. For dropless and for sutureless. For pre-op sedation and for pupil dilation. And, of course, for pain. Here’s a review of 6 relatively new medications your eye doctors might soon want to use. In alphabetical order: Dextenza, Dexycu, Inveltys, MKO Melt, Omidria and ReSure Sealant.

Dextenza

Dextenza (dexamethasone insert) 0.4mg is a corticosteroid intracanalicular insert that the surgeon places through the punctum into the canaliculus to treat ocular pain. It’s designed to deliver a tapered dose of dexamethasone to the ocular surface for up to 30 days without preservatives, says Ocular Therapeutix. Following treatment, Dextenza is intended to resorb and exit the nasolacrimal system without the need for removal. Dextenza has completed Phase 3 evaluation for the treatment of ocular pain and inflammation following ophthalmic surgery, but is currently limited to investigational use only.

Dexycu

Dexycu (dexamethasone intraocular suspension) 9% is an extended-release steroid that replaces eye drops after cataract surgery with a single shot. The FDA-approved EyePoint Pharmaceuticals’s Dexycu in February. A single injection of Dexycu administered at the site of action at the conclusion of surgery treats post-op inflammation and dispenses with weeks of post-op eye drops. So-called dropless surgery benefits patients by eliminating noncompliance and dosing errors associated with the current practice of relying on the patient self-administering drops several times daily for weeks following cataract surgery, says the company.

“Anything to reduce drops is a win-win for all of us,” says John Kraves, BSN, the ASC manager at Northwest Eye Surgeons in Renton, Wash.

Inveltys

Inveltys (loteprednol etabonate ophthalmic suspension) 1% is another new option for post-surgical inflammation and pain following ocular surgery. The FDA approved the twice-a-day topical ocular corticosteroid in August. It’s the first topical ocular corticosteroid with twice-daily (BID) dosing rather than standard four-times-a-day dosing, says Kala Pharmaceuticals. Inveltys is also the first product to employ the company’s mucus-penetrating particle (MPP) technology, which uses selectively sized nanoparticles to more efficiently deliver the drug to target tissues, says the company.

MKO Melt

The MKO Melt (midazolam/ketamine/ondansetron) has ushered in “IV-free anesthesia.” You give patients 1 to 3 of the non-opioid tablets, which dissolve under the tongue. You can give them in divided doses, first one and then another if the patient’s not sedated enough. Each sublingual troche is $13, says Imprimis Pharmaceuticals.

How well does MKO Melt work? Anesthesiologist Maggie Jeffries, MD, presented a poster at last month’s American Academy of Ophthalmology that summarized the results of her 600-plus-patient study to compare the conscious sedation efficacy of MKO Melt to diazepam (Valium) and a diazepam/tramadol/ondansetron combination during cataract surgery. The study — titled “Conscious sedation efficacy of the novel medication, MKO Melt, during cataract surgery” — measured how many patients anesthesiologists had to convert to IV in the operating room due to anxiety or pain. The results: 26% of the MKO patients required IV medication and 38% of the valium group needed IV medication.

“IVs are one of the main discomforts of cataract surgery.” says T. Hunter Newsom, MD, founder of Newsom Eye & Laser Center in Tampa, Fla. “The MKO Melt is a really great and simple way to have fewer IVs and less of an anesthesia presence. And it’s more titratable than giving valium.”

Omidria

Omidria (phenylephrine and ketorolac intraocular solution) 1% / 0.3%, the injectable that helps maintain pupillary dilation intraoperatively, is now once again separately payable. The drug enjoyed 3 years of “pass-through” status, meaning that the cost was fully refunded in hospitals and refunded 80% in ASCs, but Omidria lost its pass-through effective Jan. 1, 2018. This spring, though, Congress voted to give the drug 2 more years of pass-through status. Following a 9-month hiatus, the extension began Oct. 1 and will remain in effect until Oct. 1, 2020. The HCPCS code is C9447. Omeros continues to pursue permanent separate payment for Omidria.

Cost is a major issue. One surgery center administrator says her facility pays $395 to $450 a bottle, depending on volume. In the last quarter, she says her facility used 300 bottles of Omidria and was reimbursed fully for each. Eight of her of 9 cataract surgeons use it.

“If it’s going to help the patient and the patient doesn’t have to pay out of pocket for it, why not use it?” she asks. “Some of my surgeons become faster with it because they don’t have to administer so many different meds. Patients lie still longer and won’t feel the pressure of the procedure.”

Anna Risdorfer, RN, director of nursing at Palisades Eye Surgery Center in Bethesda, Md., came up with a simple way to ensure her facility is reimbursed for Omidria. They place a green “OK to bill” sticker next to names of the patients on the schedule whose insurers will pay for the drug.

ReSure Sealant

ReSure Sealant seals clear corneal incisions following cataract surgery. It’s prepared and applied in about 20 seconds and gels in-situ, protecting incisions in the immediate post-operative period when wounds are most vulnerable, says Ocular Therapeutix. The hydrogel gradually sloughs off in the tears during reepithelialization, so there is no need for removal. ReSure Sealant is indicated for intraoperative management of clear corneal incisions (up to 3.5mm) with a demonstrated wound leak for which a temporary dry surface can be achieved, in order to prevent post-op fluid egress from such incisions following cataract surgery with IOL placement in adults, says the company.

“It’s good for those surgeons who don’t have the most secure wounds or for those who have a higher incidence of shallow chambers or leaky wounds,” says Dr. Newsom. “It gives you a little more reassurance.” OSM