Embracing Drop-Free Treatment

Credit: Headshot supplied by Nicole Fram

Will patient care post-ocular surgery ever be truly drop-free? Owing to new sustained drug delivery technology, the field of ophthalmology is certainly moving in that direction.

Historically, drop-heavy regimens – including topical steroids, antibiotics, and NSAIDS – have been essential to reduce complications in the post-surgical period. But this strategy comes at a cost, including lack of compliance, rising out-of-pocket price tags on the patient side, and inefficiency for clinicians seeking prior authorizations.

Fortunately, given the safety and efficacy of the intracameral and intracanalicular adjunctive medicines already on the market, reducing drop burden is achievable. These medicines include Dextenza (dexamethasone ophthalmic insert 0.4mg), Omidria (Phenylephrine 1%/ketorolac 0.3%), and intracameral antibiotics.

In an attempt to reduce patient burden by going drop-free or using fewer drops, some physicians have combined these medications. Meanwhile, a number of novel drop alternatives designed to help prevent complications following ocular surgery are making their way through the pipeline.

Though ophthalmologists generally recognize the advantages of reducing reliance on drops, many are reluctant to stray from their community’s standard of care. It will take a growing number of early adopters to pave the way for widespread acceptance of reduced-drop regimens.

Advantages of fewer drops
 

In recent years, I have offered Omidria and/or Dextenza to many eligible patients, in some cases due to their requests for limited post-surgical drop regimens. Intracameral options I have also used include moxifloxacin preservative free 0.5% or 1% or intracameral dexamethasone phosphate 0.1%/moxifloxacin 0.5% compounded medications. In addition to supporting outstanding patient outcomes, this option has saved significant time in the clinic due to less call backs for non-covered topical medication.

Dextenza adds approximately one minute to ocular surgery, but it’s a worthwhile trade-off for the time we save our clinic staff by eliminating or reducing adjunctive steroid drops. In fact, in the space of a year, reduced drop regimens could easily save a practice the equivalent of a full-time employee’s hours.

My team and I launched two post-market investigator-initiated trials to further investigate the insert’s safety and efficacy, originally established in the three randomized studies that led to its approval (1). I typically use one drop of an NSAID postoperatively for four weeks in addition to intracanalicular Dextenza.

As well as saving time, fewer-drop treatments may also save money for clinics. I’ve found that Dextenza and Omidria can be more cost-effective than drops, as each of their developers has created a clear path to reimbursement for many patients.

The bottom line is that drop-free or fewer-drop treatments may offer an unprecedented level of convenience without sacrificing safety or efficacy.

Will our future be drop-free?
 

I expect our quest toward drop-free treatment to continue as new technologies reach the market.

One promising technology in the early clinical stage is OcuRing, a bioerodible drug-eluting technology that attaches to the haptic of the intraocular lenses implanted during cataract surgery, allowing the delivery of ketorolac or steroids without any shift in surgical technique (2,3). Another interesting technology currently in clinical trials is a drug-eluting IOL that delivers an IOP-lowering medication, bimatoprost, to treat glaucoma (4). These options will hopefully add to compliance and better patient outcomes and experiences.

Ocular surgery can be difficult for patients, who are faced with explanations of complicated surgeries, a host of lens choices, and their own anxiety. How wonderful it would be if they didn’t have to juggle multiple tapered drop regimens during their recovery!

Ultimately, I believe we should be open to a reduced drop burden for our patients as a preferred standard – one that will boost compliance, improve ocular surface outcomes, and streamline practice. Personally, I look forward to collaborating with fellow early adopters who are ready to step forward and help drive this change.