Injecting New Life Into Cataract Surgery

Administering medications in the eye during cataract surgery helps surgeons perform the procedure safely and promotes post-op healing. Old standbys offer cost-effective options and sustained-release formulations improve patient satisfaction by reducing the need for topical drops to lower the risks of post-op inflammation and infection.

It's common practice for surgeons to administer an anesthetic or an anesthetic-dilating combo such as lidocaine plus epinephrine or lidocaine plus phenylephrine at the beginning of the case, according to Uday Devgan, MD, a cataract surgeon in Los Angeles who runs a popular website dedicated to teaching eye surgeons about the various techniques of cataract surgery (cataractcoach.com).

"Most surgeons administer a fluoroquinolone such as preservative-free moxifloxacin at the end of case to reduce the risk of post-op endophthalmitis," he says Dr. Devgan. "A large European study also showed post-op administration of intracameral cefuroxime significantly reduced the risk of endophthalmitis."

Some surgeons inject an anesthetic and dilating agent such as epinephrine and phenylephrine at the beginning of case and administer intracameral steroids and antibiotics at the case's conclusion to reduce the risk of endophthalmitis, according to Dr. Devgan. He also says some surgeons inject an antibiotic-steroid combination through the zonular apparatus of the eye and into the vitreous to reduce the number of drops patients need to self-administer after surgery.

"Minimizing the eye drop burden for patients is an important goal," says Cynthia Matossian, MD, FACS, founder of Matossian Eye Associates, an ophthalmology practice with locations in Pennsylvania and New Jersey, and vice president of the American College of Eye Surgeons. "Regimens can be confusing, especially for the older patient population who undergo cataract surgery, and can be bothersome to patients who resent having to follow a drop schedule that might interfere with their daily activities. Compliance with prescribed post-op regimens is a significant issue, and limiting the number of drops they have to self-administer has the potential to improve outcomes."

• Dexycu is an FDA-approved intraocular dexamethasone suspension in a biodegradable sustained-release aqueous sphere placed in the posterior chamber, under the iris, at the conclusion of cataract surgery to prevent post-op inflammation. The FDA approval increases surgeon and patient confidence in the product, according to Dr. Matossian. She points out surgery initiates the inflammatory response and surgeons want to minimize the inflammatory cycle as soon as possible, which she says Dexycu can help accomplish. She says administering the medication in tissue near the iris and ciliary body before surgery prevents inflammation from the beginning and administering it behind the iris at the conclusion of surgery before sealing the incision helps minimize post-op inflammation.
• Dextenza, a dexamethasone intracanalicular implant, can be inserted into the inferior punctum at the conclusion of surgery. The plug stays in place for up to 30 days, delivering a higher initial dose and tapering over time.

"Both of these options take control back from the patient and give it to the surgeon, reduce the drops that need to be administered and deliver a steroid over 30 days with a tapering, which delivers more steroids immediately after surgery and less over the 30-day period," says Dr. Matossian.

Dr. Devgan says they could prove particulary useful during certain challenging cases. For example, patients who present for surgery with uveitis are more prone to suffering post-op inflammation, points out Dr. Devgan. "In addition to prescribing topical steroids, adding Dexycu in the eye would provide for help in preventing the complication," he says.

He acknowledges a risk of leaving medication in the eye after surgery. "It's not always known if a patient has steroid response glaucoma," he says. "A patient who's taking drops can stop administering them, but a surgeon would have to reenter the eye to remove the sphere."

He also points out the sphere can shift after it's placed behind the iris, requiring, in some cases, a second surgery to remove it. Dextenza's intracanalicular plug, on the other hand, can be removed if the surgeon notices a post-op increase in intraocular pressure.

• Omidria. This combination of ketorolac and phenylephrine is added to balanced salt solution and infused into the eye throughout surgery to help maintain pupil dilation and provide an anti-inflammatory effect. Prostate medications such as Flomax affect the iris muscle and increase the risk of floppy iris syndrome, which occurs in 75% of men on those medications and in 25% of the general population. Miosis can occur in patients who are not on Flomax or who don't remember or realize they're taking a medication with similar properties, points out Dr. Matossian.

"Establishing and maintaining a dilated pupil lets surgeons operate safely and effectively," she says. "Pupils constricting unexpectedly leads to a higher risk of complications." Omidria has also been shown to reduce pain during surgery and in the immediate post-op period, according to Dr. Matossian.

The commercially produced medications are expensive — adding between $450 and $700 per case — and therefore cost prohibitive without pass-through status, which allows facilities to bill CMS separately for the drug. With Omidria's pass-through status expiring on Oct. 1, CMS no longer provides a separate reimbursement for the drug.

Omeros, the maker of Omidria, is pursuing separate payment coverage under "no opioid" legislation, which applies to non-opioid pain management surgical drugs that are used in the surgery center setting and considered a surgical supply under CMS' Outpatient Prospective Payment System. Omeros says Omidria meets those criteria and qualifies for separate payment for the rest of 2020 and 2021. There was no update available on Omidria's payment status at the time of print. The pass-through statuses of Dexycu and Dextenza remain in place through 2021.

The price of medications used during cataract procedures is a significant factor as CMS pays surgeons about $500 per case and reimburses facilities about twice that amount. "There are low-cost options in intracameral medications with long tracks records of success and are accepted as the norm in cataract surgery," says Dr. Devgan. "Still, I welcome innovation and like having more tools in my toolbox." OSM