• Dropless Cataract Surgery: Steps Toward a New Path

    Diligent patient compliance with postoperative medications is of paramount importance to ensure optimal outcomes following cataract surgery.

    However, the burden of eye drops is a real challenge, especially for the aging population. Patients are often unable to afford medications or use them correctly in the postoperative period. Also in the midst of the COVID-19 pandemic, patients are reluctant to use eye drops for fear of acquiring or spreading disease.

    The good news is that there are promising developments toward a more “dropless” cataract surgery. Below are some of the various strategies and therapeutic options you can take advantage of to further enhance the surgical care you provide to your patients while also reducing their medication burden.

    Compounded Formulations

    After cataract surgery, many surgeons employ a regimen of a topical nonsteroidal anti-inflammatory (NSAID) medication over a two- to four-week postoperative period. These multidrop regimens can be overwhelming and also costly for patients.

    But with the advent of compounded formulations, patients can now obtain one medication bottle that contains all three components of this conventional medication regimen. This formulation obviates the need for the patient to purchase multiple medications of varying costs, and postoperative dosing and duration can be easily determined by the physician and then relayed to the patient. In addition, the surgeon can order the formulation to specific pharmacies at the time of the surgical consultation, and it will be shipped directly to the patient’s home prior to surgery.

    Intracameral Agents

    Another way to reduce postoperative drop burden is by implementing various intracameral agents at the time of cataract surgery. Intracameral phenylephrine 1% and ketorolac 0.3% solution (Omidria) is used by many surgeons intraoperatively and has been shown to not only prevent intraoperative miosis, but also reduce postoperative ocular pain and cystoid macular edema. With this intraoperative medication, some surgeons have eliminated topical steroids and NSAIDs from their postoperative regimen altogether.

    Intracameral antibiotics have also changed the landscape for the use of postoperative antimicrobial drops. Moxifloxacin, for example, can be injected intracamerally at the end of a cataract procedure as opposed to using a topical antibiotic drop. Compounded formulations of combination dexamethasone and moxifloxacin are also available, which can be injected intracamerally. As a result, surgeons can thereby eliminate both topical antibiotic and steroid drops from their postoperative regimens.

    Topical Steroid Alternatives

    Topical steroid drops are often the most burdensome to patients following cataract surgery because the drops typically require a tapering schedule and longer duration of use. The development of intracanalicular steroid inserts and injections is therefore very promising for both surgeons and patients.

    Insert: The sustained-release, preservative-free intracanalicular dexamethasone ophthalmic insert 0.4 mg (Dextenza), for example, is placed into the lower eyelid canalicular system at the conclusion of cataract surgery in less than one minute following dilation of the lower eyelid punctum. In the rare circumstance that a patient’s anatomy precludes placement of the insert, the surgeon can dilate the upper eyelid punctum and insert the implant there.

    Dexamethasone is then released for 30 days. After drug delivery, the insert degrades and is ultimately cleared via the nasolacrimal duct system, obviating the need for postoperative removal.

    Injection: Dexamethasone intraocular suspension 9% (Dexycu) is a single-dose intracameral steroid that is injected behind the iris at the conclusion of cataract surgery to reduce postoperative inflammation.

    A 0.005-mL injection of this suspension creates a sphere or ampule of medication that is suspended behind the iris in the ciliary space. This medication sphere can be visualized postoperatively and continues to have effect for up to 30 days until it completely dissolves.

    Lastly, subconjunctival or sub-Tenon’s steroids such as triamcinolone or kenalog can be injected at the conclusion of surgery as a means to reduce the need for postoperative steroid regimens.

    Patient Satisfaction

    With these new technologies, cataract surgeons have several tools in their armamentarium to reduce patients’ postoperative medications. Of course, approaches for dropless cataract surgery need to be tailored to each patient specifically, depending on comorbidities and insurance coverage, and must fit each surgeon’s pre-, intra- and postoperative flow.

    Ultimately, patients are very appreciative of these options for reducing not only the number of eye drops, but also medication-associated expenses. Surgeons are already witnessing both reductions in patient callbacks and increases in patient compliance and satisfaction.

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    Nandini Venkateswaran, MDNandini Venkateswaran, MD, is a cataract, cornea and refractive surgery specialist at the Massachusetts Eye and Ear Infirmary in Waltham, MA. She is also a clinical instructor of ophthalmology at Harvard Medical School. She joined the YO Info editorial board in 2020.