My anti-inflammatory drug regimen

The goals of postoperative anti-inflammatory medications are to reduce pain, discomfort and inflammation and to prevent cystoid macular edema and prolonged or rebound iridocyclitis following cataract surgery.

In addition to clinical efficacy, my regimen has several secondary objectives. I want it to be simple for patients to remember and comply with. I want to minimize costs for the patient and the health care system. Finally, I want to reduce staff time spent explaining the regimen to patients, obtaining drug insurance authorizations, and dealing with prescription refills and pharmacy substitutions and callbacks.

Because I routinely inject compounded moxifloxacin intracamerally, I do not prescribe any pre- or postoperative topical antibiotic. I routinely prescribe a topical solution compounded by OSRX Pharmaceuticals that combines prednisolone phosphate 1% and bromfenac 0.075%. This combination solution is started immediately following surgery. The patient pays $30 directly to OSRX for a 5 mL bottle that is delivered to their home. They also phone OSRX directly (rather than my office) to order home delivery of an authorized refill if they need it. Although drug insurance does not cover this compounded product, the patient’s cost is usually lower than the combined insurance co-pay for a topical NSAID and a topical steroid. Depending on the drug plan, the combined insurance co-pay may exceed $150.

I prescribe this solution twice daily with no tapering until the bottle runs out, which is usually after a month. This regimen is easy to explain, easy to remember, easy to comply with — compared with dosing three or four times a day — and consistently effective for uncomplicated cataract surgery. When I want stronger dosing, rather than increasing the topical drop frequency, I add an inferior subconjunctival 4 mg injection of triamcinolone (10 mg/mL solution), as described by Shorstein. Indications for adding triamcinolone would include diabetes, an epiretinal membrane and greater surgical trauma, such as with a brunescent nucleus or mechanical pupil dilation.

Some surgeons have gone “dropless” by routinely employing an extended delivery steroid regimen. Commercially marketed options include a biodegradable dexamethasone insert (Dextenza, Ocular Therapeutix), which is placed into the lower lid canaliculus, and an intraocular 9% dexamethasone suspension (Dexycu, EyePoint Pharmaceuticals). I do not personally use these products because their cost is close to $500 each. In our recent analysis of the poor utilization of these two products among Medicare beneficiaries, we noted that qualifying for the Medicare pass-through program dictates pricing policies that make these products significantly more expensive than traditional corticosteroid eye drops (Dai).

Although others inject sub-Tenon’s triamcinolone in everyone to eliminate all drops, I find a topical NSAID effective in preventing clinical cystoid macular edema, as supported by several studies (Wielders). The topical twice-daily steroid also improves patient comfort during the first postoperative weeks by quieting the ocular surface. Finally, our 2011 study found that eyes with longer axial lengths were much more likely to be severe steroid responders (Chang). Therefore, I employ loteprednol in eyes with glaucoma or with 27 mm to 28 mm axial lengths; I use a topical NSAID only in eyes with axial lengths greater than 28 mm.

• References:
• Chang DF, et al. J Cataract Refract Surg. 2011;doi:10.1016/j.jcrs.2010.10.051.
• Dai X, et al. JAMA Ophthalmol. 2023;doi:10.1001/jamaophthalmol.2023.3389.
• Shorstein NH, et al. Ophthalmology. 2024;doi:10.1016/j.ophtha.2024.03.025.
• Wielders LHP, et al. J Cataract Refract Surg. 2018;doi:10.1016/j.jcrs.2018.01.029.

• For more information:
• David F. Chang, MD, a Healio | OSN Cataract Surgery Board Member, can be reached at dceye@earthlink.net.

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