Drug options proliferate for cataract surgery patients
By Rich Daly, Contributing Writer; Featured on EyeWorld.org
Surgeons have seen an increase in the number of medications and drug delivery vehicles for cataract surgery, and more options are expected soon.
Damien Goldberg, MD, uses topical antibiotic, steroid, and NSAID therapy postop, because the research literature supports the combination of steroid and NSAIDs to reduce CME, he said. Antibiotics, of course, are critical to fight infections after cataract surgery.
“The combination has been shown to be more effective than each agent alone in some studies,” said Y. Ralph Chu, MD.
As for delivery of the drug combination, Dr. Goldberg said, options are emerging for ophthalmologists to place it directly inside the eye.
“For now, most ophthalmologists have general confidence in topical therapies as an effective and cost-effective means of protection,” Dr. Goldberg said.
The main disadvantage of using topical therapy, Dr. Chu said, has been patient compliance; the increasing cost of medications has restricted access to many new therapies for some patients. Some cataract surgeons have begun to use injections of a corticosteroid and fluoroquinolone (dexamethasone/moxifloxacin HCI, OMNI, OSRX, an affiliate of Ocular Science), while Dr. Goldberg has started to use Dextenza (dexamethasone, Ocular Therapeutix), an intracanalicular corticosteroid insert placed in the punctum. “It’s exciting that all of these things are starting to come out,” Dr. Goldberg said. “The biggest barrier with these new therapies is how everything is going to be paid.”
Payment limitations from health plans has limited Dr. Goldberg’s use of the newer delivery options. Surgeons and patients have many post-cataract medical options for topical therapy, Dr. Chu said. His practice educates patients about the available choices and helps them tailor a treatment regimen based on their specific needs and considerations like the type of surgery, medical history, allergies, risk factors, and affordability.
“We always try to ensure the patients choose the most efficacious therapy first and then find ways to help make that as affordable as possible for each patient,” Dr. Chu said. “In our experience, it is very difficult to generalize a therapy regimen across the board to every patient because of the new complex landscape.”
Dr. Goldberg previously preferred brand-name drug products, but as prices increased sharply over the last 10 years, his practice started to look for alternative solutions, such as compounding. He has become a regular user of a compounded combination of topical antibiotic, steroid, and NSAID (prednisolone/gatifloxacin/bromfenac, OMNI, OSRX).
Advantages of this approach include improved compliance by patients, preventing health plans or pharmacies from changing or denying prescribed medications, and eliminating “extensive staff time to deal with all of the medication callbacks” from health plans, Dr. Goldberg said. “We felt empowered and in control again, using the compounded medicine,” Dr. Goldberg said.
“It made it so much easier to use and beneficial for patients.”
Subsequent research showed that inflammation was reduced in patients treated with the compounded combination. In a randomized, double-masked prospective U.S. multicenter study by Fram et al., OMNI demonstrated 50% reduction in summed ocular inflammation score over the 23% reduction seen with the control of Pred Forte (prednisolone, Allergan), Vigamox (moxifloxacin, Novartis), and Ilevro (nepafenac, Novartis).1 “I’m sure some of the success of OMNI is from the simplified patient use to one bottle a couple of times a day instead of three different bottles on three different dosing schedules,” Dr. Goldberg said.
Dr. Chu, who has experience with many intracameral and combination therapies, uses intracameral drugs for patients who may have difficulty using topical drops or who have medical conditions, such as diabetes and inflammatory conditions, which may increase their risk of CME or prolonged postop healing.
“We have had good experience with intracameral and subconjunctival medications, but some patients had slower visual recovery, and some had more postop inflammation than others,” Dr. Chu said.
Dr. Goldberg has experienced good results from the use of intracameral injections, although use among his patients has been limited by health plan payment.
“If I could do it, I would,” Dr. Goldberg said. “There’s good data that supports the use of intracameral moxifloxacin.”
Dr. Goldberg expects intracameral medications, including those inserted into the cannula, to gain traction among cataract surgeons.
Dr. Chu, who has participated in FDA clinical trials using punctal plugs to deliver drugs, said such therapies are promising and attractive because plugs can be removed and, theoretically, titrated based upon how many plugs are placed. Dr. Goldberg, who participated in clinical trials for Dextenza, said it has provided clinical benefits to patients, but wider use of it awaits Medicare payment approval.
An intracameral option for dilation is Omidria (phenylephrine and ketorolac injection, Omeros). Dr. Chu, who uses a standard drop dilation regimen, participated in the clinical trials for Omidria and found it effective. His practice is now conducting some post-market evaluations of the product.
Although some practices have had good results with Omidria, Dr. Goldberg said payment issues continues to limit his use of that treatment. Dexycu (dexamethasone, EyePoint Pharmaceuticals) is another promising intracameral option to treat postoperative inflammation.
About the doctors
Damien Goldberg, MD Partner Wolstan & Goldberg Eye Associates Torrance, California
Y. Ralph Chu, MD Founder, medical director Chu Vision Institute Bloomington, Minnesota
1. Fram N, et al. Prospective U.S. multicenter study of safety and efficacy of combination drop prednisolone phosphate, moxifloxacin, and ketorolac in treating postop inflammation and pain after cataract surgery. 2017 ASCRS•ASOA Symposium & Congress.
Goldberg: Ocular Science, Ocular Therapeutix