Management of post-cataract inflammation, which contributes to delayed visual recovery and discomfort, is a critically important perioperative responsibility. Corticosteroids act on the arachidonic acid pathway, early in the inflammatory cycle, to inhibit pro-inflammatory prostaglandin release. To me, these agents are the most powerful tool we have to prevent inflammation and pain, but I also like to have the synergistic effects of non-steroidal anti-inflammatory drugs (NSAIDs), which block prostaglandin synthesis by inhibiting downstream cyclooxygenase (COX) activity.

Despite the importance of these medications, surgeons cannot have great confidence that the drugs will actually reach their intended target tissues when given as traditional topical drops. The rate of nonadherence with topical medications is estimated to range from 30% to 80% (1). Polypharmacy significantly increases the challenges of adherence with topical regimens. Our patients forget to instill drops or mix up the dosing frequency; they often miss the eye entirely or instill too many drops in succession, washing out much needed medications.

I have taken a variety of approaches to helping my patients overcome these challenges. I made visual charts to help patients keep track of post-cataract dosing schedules, but these were often ignored or lost. For a while, I used and advocated for compounded combination drops as a way to minimize the number of bottles and instillations. However, I found that insured patients were often resistant to obtaining medications from a compounding pharmacy. Psychologically, they felt they were leaving benefits on the table, even if their insurance co-pay might ultimately cost them about the same as the compounded drops.

Eliminate drops

Ultimately, I think the best solution is to rely as much as possible on intraoperative or sustained-release medications to limit the burdens of polypharmacy. My current regimen includes an intracameral injection of the antibiotic moxifloxacin at the conclusion of the case, along with placement of an intracanalicular dexamethasone insert (Dextenza, Ocular Therapeutix) whenever possible. This ensures that patients are protected from inflammation and infection, without regard to their memory, manual dexterity, or willingness to instill drops. The use of a sustained-release steroid, in particular, has the advantage of eliminating the drop with a tapering schedule, greatly reducing the complexity of the postoperative regimen.

I still prescribe a topical NSAID for every patient. In most cases, I can choose a once- or twice-daily NSAID, so the drop burden is minimal. I am currently considering eliminating NSAIDs in some cases. Some of my colleagues have opted for an intracameral NSAID strategy, utilizing intracameral ketorolac and phenylephrine in the irrigating solution (Omidria, Rayner) to flush the anterior chamber with NSAID throughout the surgery. However, I haven’t seen sufficient evidence yet to convince me that it provides the same efficacy as a topical NSAID during the postoperative period. 

I find that my patients are pleasantly surprised to learn they only need one drop after surgery. They may have had friends or family members who had cataract surgery and went home with three different drop bottles and a complicated schedule, so they are thrilled to have an easier postoperative course. 

Other than the NSAID, the only time I add additional topical drops post-cataract surgery is for patients with a moxifloxacin or fluoroquinolone allergy who need a different class of antibiotic that can’t be given intraoperatively. Rarely, when there is significant corneal edema, I may add a supplemental topical steroid, usually Pred Forte, for two weeks. 

Glaucoma patients

Patients with glaucoma present unique challenges. These patients are typically already on one or more IOP-lowering drops daily, so I’m even more reluctant to add to their drop burden with postoperative medications. On the other hand, there is some evidence that patients with glaucoma and/or those on a prostaglandin analog medication may be a higher risk for cystoid macular edema (CME) (2), so we definitely need to control inflammation in these patients. I was initially skeptical about keeping a strong steroid like dexamethasone on the surface for longer with an intracanalicular insert, fearing that it might contribute to an IOP spike in a class of patients already vulnerable to IOP fluctuations. However, a recent IRIS Registry study demonstrated that glaucoma patients did not have any elevated risk of IOP increase compared to non-glaucoma patients with intracanalicular dexamethasone (3), which I find very reassuring. In my personal experience, preservative-free Dextenza has been very well tolerated in glaucoma patients and I do not exclude them from receiving it.

My glaucoma colleagues are very interested in new and emerging sustained-release delivery options for longer-term, drop-free control of IOP, such as the iDose TR travoprost implant (Glaukos) and Durysta bimatoprost implant (Allergan). Spyglass Pharma has an IOL in late-stage development that incorporates sustained release of glaucoma medications via nonbioerodible drugs pads that attach to the optic-haptic juncture; the same technology is also being evaluated for release of an NSAID after surgery. I expect we will continue to have expanding options for drop-free pharmaceuticals in both the postoperative and glaucoma settings.

Site of service and coverage

Payment methodologies for dropless steroid and NSAID approaches have been evolving, as well.  I perform the majority of my cataract surgery cases in the hospital outpatient department (HOPD) setting, although I also operate in an ambulatory surgery center (ASC). As more cases migrate into ASCs, understanding how sustained-release and intraoperative technologies fit into both sites of service remains key to understanding access to advanced options.

In both ASCs and HOPDs, drugs indicated for pain, such as Dextenza and Omidria, can be billed as a separate non-opioid pain management surgical supply charge using the appropriate J codes (J1096 for Dextenza and J1097 for Omidria) for patients with fee-for-service Medicare. Sustained-release steroids that are not specifically indicated for pain, such as Dexycu (EyePoint Pharmaceuticals), do not fall under this definition and therefore do not qualify for separate payments. In either setting, surgeons can also use CPT code 68841 to be reimbursed for insertion of an intracanalicular insert. Manufacturers also typically offer assistance programs for eligible patients with commercial insurance.

What this means is that site of service need not be a significant factor in the choice of anti-inflammatory therapy. Clinicians can continue their dropless agent of choice in either the HOPD or ASC without undue financial barriers. For younger, healthy patients, my site-of-surgery choice is based primarily on the most convenient location for the patient and schedule availability. These patients can safely be treated in an ASC or even an in-office surgery suite, for those with access to such facilities. The advantages of the HOPD include ease of access to equipment and other subspecialists, as well as expert anesthesiologists for patients with significant medical comorbidities and the full resources of the hospital next door, if needed. Cost is less of a consideration than in an ASC, so if I have a case that's going to take longer and is likely to be more complicated or require more surgical resources, I am more comfortable performing that case in the HOPD. Regardless of location, I find that intraoperative technologies are most reliably covered for those who have Medicare with a strong secondary insurance, and I always make the choice to reduce drops for these patients.

As someone who has been exploring dropless and sustained-release medications since I was a resident, I have seen firsthand how reducing the burdens of polypharmacy can improve the patient experience. Reliable, hands-free alternatives to traditional postoperative topical drops, particularly in glaucoma and other complex patients, helps support adherence, reduces drop burden, and streamlines postoperative care.