February 17, 2022

Removing at-home drop regimens eliminates compliance and administration issues.

After a typical cataract surgery, patients must safely and properly administer a staggering number of drops at home in the ensuing days and weeks to prevent infection and inflammation. Unfortunately, many patients don't use proper technique or stick to the rigorous schedule.

Neal Shorstein, MD, an ophthalmologist at Kaiser Permanente in Walnut Creek, Calif., says several studies show that most cataract patients instill drops incorrectly. For example, they may touch the tip of the eye drop bottle, scrape the cornea during administration or miss the eye altogether. He sees a solution to this problem in the form of the thousands of "dropless" cataract surgeries he has performed.

At the end of a cataract procedure, Dr. Shorstein injects the antibiotic moxifloxacin into the eye's anterior chamber to reduce the risk of endophthalmitis. No FDA approved moxifloxacin product is currently indicated for this use, so the drug must be compounded by a vetted 503B outsourcing pharmacy. "Ordering it, setting up shipping and having it stored properly takes some preparation and time," he notes.

While many surgeons still prescribe topical antibiotic drops in addition to administering the intraoperative injection, Dr. Shorstein says emerging research continues to favor the dropless trend, and increasing numbers of physicians are realizing topical drops aren't necessary when injections are administered.

Dr. Shorstein also injects triamcinolone, a sustained-release, long-acting steroid, into the subconjunctival space at the end of surgery to prevent post-op inflammation. He says this off-label use of an FDA approved product is as effective as administering topical steroid drops.

Two FDA approved products, Dexycu and Dextenza, have recently emerged to give surgeons another effective option for administering the steroid treatment. "Both of these products remain in place for about two to three weeks and provide long-acting steroid administration to the eye," says Dr. Shorstein. "These drugs definitely give us surgeons peace of mind, while patients love the practice because they don't need to constantly put in drops throughout the day."

Surgeons debate the benefits of performing concurrent surgeries on the same day.

Patients with cataracts in both eyes prefer to have two new lenses implanted during a single surgical visit, according to ophthalmic surgeon Andrew Shatz, MD, owner of SightTrust Eye Institute in Sunrise, Fla. He decided to begin offering immediately sequential bilateral cataract surgery (ISBCS) after poring over the clinical evidence and finding that performing back-to-back procedures is safe and effective.

"Patients don't need to make two trips to the facility for staggered procedures performed on separate days," says Dr. Shatz. "That means they avoid two rounds of anesthesia, healing and burdensome post-op drop regimens."

He believes the advantages of ISBCS — which reportedly include quicker vision rehabilitation and reduced costs of care — outweigh the extremely small risks of bilateral endophthalmitis and blindness, thanks to surgeons using intracameral antibiotics and managing post-op inflammation of ocular tissues. Proponents of ISBCS believe poor refractive outcomes — a concern because surgeons can't benefit from analyzing the outcomes of the first procedure before performing surgery on the second eye — are also exceedingly rare based on the use of biometry to take precise eye measurements that lead to more exact determinations of the most effective IOL power to use.

However, some surgeons remain concerned about the potential for post-op complications and poor refractive outcomes when two procedures are performed on the same day. Samuel Masket, MD, a clinical professor of ophthalmology at the David School of Medicine's Stein Eye Institute at UCLA, is one of them. In an editorial published in the journal Ophthalmology, he points to the associated risks of endophthalmitis and toxic anterior segment syndrome. Although Dr. Masket concedes prophylactic intracameral antibiotics and proper sterile technique mitigate these risks, he says the potential complications are devastating to patients and their families.

Dr. Masket also points out that physicians and surgery centers are reimbursed 50% for a second eye surgery performed on the same calendar day under traditional fee-for-service Medicare reimbursements, which he says creates a significant financial disincentive for ISBCS. While he does believe that ISBCS would benefit patients who must travel great distances for surgery, require general anesthesia or have limited social support systems for recoveries, he doesn't believe performing bilateral procedures is worth the risks for most patients.

"Does the patient truly benefit?" he writes. "At present, at least with regard to surgery under traditional Medicare reimbursements, it appears as though the surgeon is financially compromised and the patient is put at greater risk, whereas the third-party payer is the ultimate beneficiary."

Surgeons need access to the most precise visual data and reliable, high-resolution camera systems for the best outcomes.

Ophthalmic surgeons are busier than ever as the aging population and younger generations look to them for procedures that ensure good eyesight and eye health. The best outcomes for patients result from a combination of utilizing first-rate imaging devices and the continuing education of the latest techniques and technologies available today. Manish Desai, Regional Sales Director at Panasonic i-PRO Sensing Solutions Corporation of America, offers the following insights on the industry and what eye surgeons can look forward to in the future.

Q: For today's eye surgeon, how important is the image when performing a variety of outpatient procedures?
There is a direct correlation between the resolution and color reproduction expected from the cameras that are employed for outpatient procedures and the level of precision provided during the procedure. The images are essentially visual data, providing physicians the information they need to perform various tasks. It is critical that physicians have access to the most precise visual data possible to ensure the best patient outcome when performing any procedure. High levels of image detail and color reproduction are also essential for students' education.

Q: What should the eye surgeon look for when deciding on a particular system?
Aside from high-imaging performance, an eye surgeon should look for camera systems that are easy to set up, reliable and provide the greatest overall value for their capital investment.

Q: What part does compatibility with various microscopes play in the surgeon's ability to perform?
Microscope compatibility is imperative to ensure the surgeon can maintain the proper field of view and focus for anterior, posterior and glaucoma procedures. This is critical when evaluating imaging solutions.

Q: How important is the imaging system for patient safety?
Patient safety is not affected by imaging devices used to perform eye procedures. The ability to provide patients with a high-resolution video of their eye procedure helps reinforce patient confidence that builds strong patient-physician relationships, reputations and growth.

Q: What are the technology trends you are seeing for eye procedures in the future?
Cameras with high dynamic range provide an advantage for physicians performing eye procedures, as they allow surgeons to view both dark and bright areas within the same frame. This is not possible with conventional cameras that do not have this feature. Another emerging trend is performing procedures using a 3D digital microscope. The 3D imaging allows surgeons to use a heads-up display while operating on patients. This reduces neck strain, which is a prevalent issue with surgical microscopes. As a result, companies that produce surgical microscopes are investing in developing new 3D digital microscopes to benefit surgeons and improve patient outcomes.

Q: How does a good camera system aid in building an eye business?
High performance and reliable camera imaging devices are most important to eye surgeons and physicians. It's somewhat ironic that high-resolution camera technology has become one of the most pervasive tools used to treat, correct and maintain the organic vision quality of patients' eyes. With the proliferation of 4K camera technology, more and more surgeons are seeking 4K camera and recorder solutions for their practices.

For more information visit https://i-pro.com/us/en/medicalimaging.