Drug Advances Improve Eye Outcomes

Intraoperative medications promise reduced postoperative drop regimens, but reimbursement remains a restricting factor for eye centers.

In outpatient ophthalmic surgery, especially in terms of its core cataracts procedures, various medications have emerged that are improving experiences and outcomes for patients, providers and facilities. While reimbursements for some are spotty, and some ophthalmologists are reluctant to introduce new variables into the efficient but extremely precise procedures they have performed safely for many years, many surgeons are embracing these drug innovations in the name of an improved patient experience.

Influential innovations

Michael Repka, MD, MBA, is the 2025 president of the American Academy of Ophthalmology (AAO), a community of 32,000 ophthalmologists, and a practicing pediatric ophthalmologist at the Wilmer Eye Institute of John Hopkins University in Baltimore. “Every aspect of care is being influenced by innovations in products we have at our disposal,” he says — preoperatively, intraoperatively and postoperatively.

He notes that for decades, topical postoperative drop regimens have been the standard of practice. These include antibiotic drops to prevent infections, along with steroid drops — which have more recently given way to or been combined with nonsteroidal anti-inflammatory drug (NSAID) drops — to reduce inflammation and postoperative pain. Meanwhile, in pre-op, various agents have been proposed to keep the pupil dilated and to reduce intraocular inflammation intraoperatively.

The focus of many advances has been to reduce (but not necessarily eliminate) patients’ post-op drop regimens by administering antibiotic, anti-inflammatory and pain-relieving agents intraoperatively in or around the eye. These intraoperative medications also assist the surgeon during the procedure.

“The evolution has come in providing additional medications in the irrigation fluids that are going into the eye during the surgery — the fluid that also carries cataract fragments out of the eye,” says Dr. Repka. “That fluid can have medications in addition to salt and minerals that have been used for a long time.” He says cataract surgeons can now leave depots of antibiotic and/or steroid in the eye itself or in the canaliculus that gradually self-administer during the patient’s recovery period.

Pushing the practice forward

William F. Wiley, MD, is a Board-certified ophthalmologist who is medical director of Cleveland Eye Clinic, a division of Midwest Vision Partners, and president of the Outpatient Ophthalmic Surgery Society who has performed more than 50,000 cataract and refractive surgical procedures. Always on the cutting edge of the specialty, he participates in clinical research studies and frequently offers patients technology that is not yet widely available. He was one of the first in his region to offer his patients all-laser LASIK and laser-assisted refractive cataract surgery, along with various premium intraoperative lenses and glaucoma stents.

Dr. Wiley references “different realms” of drug advances: anesthesia, anti-inflammatory, pupil dilation and intraocular comfort. “I would say many of them are widely used,” he says. “Some doctors may be using all of them. Most doctors are using some.”

The primary obstacle preventing practice changes to accommodate new drugs, he says, often is reimbursement, which varies from drug to drug. “Some are under a pass-through. Some have their own J-code. Some are not reimbursed at all, so they are an added line-item expense to the surgery center,” says Dr. Wiley. “It’s a complicated landscape, and each product has its own reimbursement scenario. Thankfully, for many of the medications, there are reimbursement pathways.”

Popular medication advances

Numerous commercial and compounded medications are finding growing acceptance among eye surgeons.

Pupil dilation. Most of the action in this intraoperative phase of the episode of care is focused on a compounded option and a more recently introduced commercial option. The compounded medication, epi-Shugarcaine, mixes epinephrine for pupil dilation and lidocaine to numb the eye. It’s administered intracamerally through an injection into the anterior chamber of the eye. A newer FDA-approved commercial option uses phenylephrine to maintain dilation and ketorolac, an NSAID, for pain relief and inflammation control. This drug is added to the irrigating solution used during surgery.

Anesthesia. Intravenous anesthesia has long been the standard for cataract surgery, but oral sedation is emerging as a patient-pleasing IV-free alternative. The oral sedation agent is a compounded drug that consists of midazolam, ketamine and ondansetron, known among providers as an MKO melt. “It’s gaining traction for patient comfort and creating a great experience,” says Dr. Wiley.

Anti-inflammation. Two commercial products are preservative-free, extended-release corticosteroids that offer different modes of delivery to reduce the postoperative need for topical steroid drops. Dexamethasone is a delivery system that is inserted into the canaliculus to treat postoperative ocular inflammation and pain. Another commercial product is an injectable intracameral suspension of triamcinolone acetonide. Dr. Wiley says a compounded option combining triamcinolone acetonide and the antibiotic moxifloxacin can be injected intraocularly or Sub-Tenon’s to decrease inflammation while also helping to prevent rare but devastating endophthalmitis infections.

Antibiotics. Intracameral moxifloxacin is in fairly widespread use now, says Dr. Repka. “It’s used to reduce the rate of endophthalmitis, but it also eliminates the need for postoperative topical antibiotics in the view of some surgeons, and that’s why it’s of a great deal of interest to surgeons,” he says.

What’s coming?

“As I think about the pipeline for us, I think it’s going to be a manufactured intracameral combo product that really reduces the need for postoperative drops,” says Dr. Repka. “If it in fact works well and is safe, it will be a huge relief for the family and for the patient to not have to administer postoperative drops, or to administer them not as frequently. Take an 80-year-old or a 90-year-old and say, ‘You need to do these drops four times a day and, by the way, there are three of them, and don’t run out of the supply in this small bottle.’ It gets really hard to ensure adequate treatment, especially if they don’t have a support network. And many don’t.”

Dr. Wiley is most excited for additional sustained-release medications under development to come online, especially an intraocular lens that comes with an attached medication suppository. “I think we’ll see, without a doubt, more and more work in that direction,” he says.

What about ‘dropless’ surgeries?

The Holy Grail of “dropless” cataract surgeries that completely remove the burden of postoperative drop regimens from patients by leveraging intracameral depots of medications is a hot topic that unfortunately doesn’t align with current realities.

One issue is the reluctance of ophthalmologists to introduce new injectable and implantable drug delivery methods that may not improve on the efficacy of postoperative drops while introducing infection risk. “I don’t think it is established in everyone’s mind whether these medications are better than postoperative drops,” says Dr. Repka.

“Comparison trials are sorely needed, and the problem is that it’s hard to undertake a trial for endophthalmitis because the rates are so low. Most intracameral injections today are compounded, not manufactured products, so they have somewhat lesser levels of FDA scrutiny in terms of manufacturing processes as well as safety and effectiveness. Some surgeons may think their patients benefit from the drop regimen during the postoperative period.”

Beyond efficacy and safety concerns, cost is another barrier to reducing or eliminating post-op drops. Dr. Repka notes the cost of some intracameral drugs administered during the case is borne by the facility, which may or may not be adequately compensated by the payor for their use. “If the patient buys the eyedrops, that doesn’t cost the facility anything,” he says. “This is both a regulatory problem and a payment policy issue. We’re at least a decade in since the problem was recognized, and it has been a slow process.”

“Without a doubt, we are in the realm of less drops.”
William F. Wiley, MD

Dr. Wiley, for his part, has whittled things down to one postoperative drop per day. “I’ve tried all the different regimens, and I personally think it’s hard to go completely dropless,” he says. “You have three different components: the steroid, the antibiotic and the NSAID. We’ve seen a lot of work in the steroid component of having sustained-release steroid or injectable steroid that can decrease the steroid drop load. In the antibiotic component, there’s been some debate as to whether it is really required, or really necessary.

“In my experience, if you don’t have an NSAID on board, you have an increased risk of cystoid macular edema (CME).

But even if you use intraocular NSAID, it can be helpful but I still don’t think it eliminates the need for postoperative NSAID,” says Dr. Wiley. “I like to use a sustained-release steroid combined with one drop a day — a triple compounder that has a steroid, NSAID and antibiotic. I’m mostly using that for the NSAID alone, which helps prevent CME. It’s not a complicated regimen; it’s relatively inexpensive compared to commercially available drops; and you have the antibiotic and steroid on board if you need to bump up the drop regimen for one reason or the other.

“I personally don’t think dropless is a viable solution until you have a sustained-release NSAID, and I don’t think we’re close to that,” says Dr. Wiley. “But without a doubt, we are in the realm of less drops. Instead of the patient using four drops a day for weeks on end with complicated regimens, you can dramatically decrease the drop burden.” OSM