Dropless cataract surgery: Shifting paradigm in postoperative care

(Image Credit: ADobeStock/fgnopporn)

Cataract surgery has undergone transformational advancements in recent years, and one notable innovation is the adoption of dropless cataract surgery. This technique aims to eliminate the need for postoperative topical eye drops, streamlining the recovery process and potentially improving patient adherence. This article reviews the principles behind dropless cataract surgery, explores its advantages in the postoperative period, and discusses its implications for patient satisfaction and overall surgical outcomes.

Cataract surgery is a routinely performed procedure globally that has traditionally involved the use of postoperative topical eye drops to prevent infection and manage inflammation. However, dropless cataract surgery represents a departure from this conventional approach by utilizing intracameral drug delivery during surgery to provide an extended postoperative prophylaxis.¹

Principles of dropless cataract surgery

The traditional regime for treating a patient who undergoes cataract surgery begins with the preoperative routine of prescribing 3 essential topical medications that the patient begins to take 1 day before surgery. These medications include an antibiotic such as a fourth-generation quinolone, a nonsteroid anti-inflammatory, and a steroid to be taken 4 times a day, starting the day before surgery and continuing for 1 week. At the end of the first week, the antibiotic drop is discontinued as long as the patient is improving. The nonsteroid and steroid anti-inflammatory topical medications are continued twice a day until 1 month post operation, at which point the medications are fully discontinued.

Dropless cataract surgery typically involves the injection of compounded medications consisting of an antibiotic, corticosteroid, and nonsteroid into the eye’s anterior chamber during the surgical procedure. This eliminates the need for the patient to self-administer topical drops postoperatively, addressing issues related to adherence, convenience, and potential complications associated with eye drop usage, such as poor dexterity in elderly patients or contamination of the bottle tip.²

The principle is that intraocular medications maintain bioavailability for at least 28 days, eliminating the need for postoperative topical medications.

Postoperative advantages

Enhanced patient adherence is one of the most important benefits of the dropless regimen. Eliminating the reliance on postoperative eye drops simplifies the patient’s postoperative care regimen. Improved adherence may lead to better outcomes, reducing the risk of complications associated with missed or improperly administered eye drops.

Reduced medication burden is a benefit that ultimately serves both patients and physicians. The patients are spared the inconvenience of multiple eye drops, potentially decreasing the likelihood of medication-related adverse effects and simplifying the postoperative recovery.

Minimized complications are well documented. Dropless cataract surgery reduces the risk of contamination associated with topical eye drops, lowering the potential for infection and inflammation. The intracameral route of drug administration may enhance the efficacy of antibiotics and corticosteroids, minimizing the risk of postoperative complications.

Eliminating the need to purchase postoperative eye drops improves cost efficiency as well.3 Dropless cataract surgery may contribute to cost savings for patients and health care systems. Often, patient coverage for medication is incomplete and leaves the patient without the required medication. Medications can sometimes be out of stock or unavailable for dispensing until after the date of surgery. Patients often wait for medications for several days, or they may have to wait for prior authorization approval before the medications can be dispensed.

Clinical evidence is mounting that documents the safety of the dropless regimen. Data demonstrate that a postoperative topical antibiotic does not reduce the risk of endophthalmitis. Patient satisfaction is also a driving force for the movement. Several studies have investigated the safety and efficacy of dropless cataract surgery, with early findings suggesting comparable or improved outcomes compared with traditional postoperative care regimens. Furthermore, patient satisfaction surveys have highlighted the convenience and reduced postoperative burden associated with this approach.

Although dropless cataract surgery offers compelling advantages, challenges such as the availability of compounded medications, potential allergic reactions, and variations in surgeon preferences should be considered. Further research is needed to establish standardized protocols and assess long-term outcomes.

The evolution of dropless cataract surgery warrants exploration into its long-term safety, comparative effectiveness, and broader adoption within the ophthalmic community. Additionally, advancements in drug-delivery technologies may further refine and expand the applications of this innovative approach.

Three-step dropless cataract surgery technique

A dropless cataract surgery technique begins with infusing 4 cc of phenylephrine and ketorolac intraocular solution 1%/0.3% (Omidria; Rayner Surgical Inc) into the balanced salt solution irrigating bag before the start of the case. After the cataract is removed and the IOL is inserted, inject 2 cc of compounded mix of dexamethasone 1 mg/mL, moxifloxacin 0.5 mg/mL, and ketorolac 0.4 mg/mL (Dex-Moxi-Ketor PF; ImprimisRx) intracamerally. Insert a dexamethasone ophthalmic insert 0.4 mg (Dextenza; Ocular Therapeutix, Inc) into the canaliculi of the respective lower eyelid.

Phenylephrine and ketorolac ophthalmic solution 1%/0.3% has been a true game changer at the forefront of the dropless regimen. The FDA has approved the agent for intraoperative dilation and postoperative pain control, and it combines 2 active ingredients: phenylephrine and ketorolac.⁴

Phenylephrine and ketorolac ophthalmic solution 1%/0.3% is administered as an intracameral injection into the eye’s anterior chamber during surgery. Its mydriatic and anti-inflammatory effects combined in a single formulation simplify the medication regimen for surgeons and patients, as it reduces the need for separate medications to achieve the same effects.

The use of phenylephrine and ketorolac ophthalmic solution 1%/0.3% is intended to enhance surgical visualization, maintain pupil dilation, and reduce inflammation and pain during and after cataract surgery. The goal is to improve surgical outcomes and enhance the overall patient experience during the perioperative period. It is important to note that the surgeon determines the use of specific medications, including phenylephrine and ketorolac ophthalmic solution 1%/0.3%, based on the patient’s needs and medical history. In my clinical experience, I have reduced the use of intracameral lidocaine-PF. Patients are more comfortable throughout the cataract procedure, and I have fewer complaints of intraoperative pain. Postoperatively, the eyes are quiet with minimal chamber cell and flare. Conjunctivae are white and quiet. Patients who have received phenylephrine and ketorolac ophthalmic solution 1%/0.3% have fewer complaints of foreign body sensation and glare.

Dexamethasone-moxifloxacin-ketorolac 1.0/0.5/0.4 mg/mL is an intraocular, preservative-free solution injected intracamerally at the end of the case, usually after insertion of the IOL. The indications are to reduce postoperative inflammation, reduce inflammation of the eye’s anterior segment, prevent bacterial endophthalmitis, and reduce postoperative pain. Possible adverse effects include delayed wound healing, increased IOP, eye irritation, and corneal edema. This compound effectively eliminates the need to use topical antibiotics, steroids, and nonsteroidal drugs. In my experience, from postoperative day 1, most corneas appear clear, and the anterior chambers are deep and quiet. Most importantly, patients have reduced redness and much fewer complaints of eye discomfort. The topical equivalent antibiotic, such as ciprofloxacin dosage 4 times daily, can be effectively eliminated. Literature shows that postoperative topical antibiotics are less effective in eliminating endophthalmitis than intracameral moxifloxacin, which garnered an endophthalmitis incidence rate of less than 1%.⁵

The third step in my dropless routine includes a dexamethasone ophthalmic insert. A health care professional places a small, resorbable insert into the lower punctum of the eye. The insert gradually dissolves over up to 30 days, releasing a controlled amount of dexamethasone into the eye. The active ingredient, dexamethasone, is a corticosteroid with anti-inflammatory and immunosuppressant properties. The sustained release of dexamethasone helps manage inflammation and pain associated with ocular surgery, such as cataract surgery.6 By offering sustained drug release, the insert may contribute to improved patient adherence and convenience during the recovery period after ophthalmic surgery.

Patient needs

It is important to note that the treating ophthalmologist determines the use of a dexamethasone insert based on individual patient needs and the specific requirements of the surgical procedure. As with any medication, patients should follow their physician’s instructions regarding its use and report any concerns or adverse effects promptly. IOP should be monitored as a possible adverse effect.

Conclusion

The term dropless cataract surgery denotes the fact that patients are not compelled to use drops as they would have traditionally had to. It represents a significant advancement in cataract surgical techniques, offering tangible postoperative advantages
for patients.

By addressing adherence issues, minimizing complications, and streamlining the recovery process, dropless cataract surgery can enhance patient satisfaction and improve overall outcomes in ophthalmic surgery. The combination of an intracameral, compounded medication such as phenylephrine and ketorolac and dexamethasone-moxifloxacin-ketorolac combined with a dexamethasone implant can result in improved adherence and reduced cost.

Further research and collaboration within the medical community will be crucial for optimizing protocols, ensuring safety, and establishing this innovative technique as a standard of care in cataract surgery.

Monique M. Barbour, MD

E: monique.barbour@ymail.com

Barbour is a board-certified ophthalmologist with Clear Vue Eye Center in West Palm Beach, Florida. She graduated with honors from Howard University College of Medicine and she then completed her ophthalmology residency at Albert Einstein College of Medicine, Bronx Lebanon Hospital Center. Following the completion of her residency, she completed a glaucoma fellowship at Georgetown University in Washington, DC. She has also received an executive master’s degree of health administration from Florida Atlantic University.

Bria George, PharmD

E: bgeor026@med.fiu.edu

George is a pharmacist and currently is attending medical school at Florida International University. She also is treasurer of the Student National Medical Association.

References:

1. Wotipka EK, Wright AJ, Fan JZ, et al. Postoperative complications of true dropless cataract surgery versus standard topical drops. J Acad Ophthalmol (2017). 2023;15(2):e144-e153. doi:10.1055/
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2. Donnenfeld ED, Hovanesian JA, Malik AG, Wong A. A randomized, prospective, observer-masked study comparing dropless treatment regimen using intracanalicular dexamethasone insert, intracameral ketorolac, and intracameral moxifloxacin versus conventional topical therapy to control postoperative pain and inflammation in cataract surgery. Clin Ophthalmol. 2023;17:2349-2356. doi:10.2147/OPTH.S422502

3. Pandey SK, Sharma V. Transzonular drug delivery during cataract surgery: is dropless cataract surgery really beneficial? Indian J Ophthalmol. 2018;66(9):1377-1379. doi:10.4103/ijo.IJO_830_18

4. Shorstein NH, Myers WG. Drop-free approaches for cataract surgery. Curr Opin Ophthalmol. 2020;31(1):67-73. doi:10.1097/ICU.0000000000000625

5. Anderson J, Young S, Cockerham G, Chomsky A, Parr NJ. Evidence Brief: Intracameral Moxifloxacin for Prevention of Endophthalmitis After Cataract Surgery. Department of Veterans Affairs (US); 2022.

6. Fram N, Alsetri H, Shiler O, Paterno PJ, Cabang J. Retrospective study of a sustained-release intracanalicular dexamethasone insert for treatment of ocular inflammation after cataract and corneal surgery. Clin Ophthalmol. 2022;16:4065-4074. doi:10.2147/OPTH.S386702