Technological Advances Offset Drop Burden for Cataract Patients and Staff

In my practice, patients have historically been prescribed three separate postoperative medications after cataract surgery: a corticosteroid, a nonsteroidal anti-inflammatory drug (NSAID), and an antibiotic. This regimen of three separate drops can be quite expensive for patients, depending on their formulary and co-pays. The complexity of the regimen also makes it challenging to manage. Many patients are having surgery on both eyes within a few weeks of each other, so the drop schedules for the two eyes may overlap. Patients who are on other medications – for dry eye or glaucoma, for example – must intersperse their chronic drops with the post-surgical ones. When patients and caregivers need a chart to keep up with times and drops, that also means the process can be quite burdensome.

We know that patients are not very good at adhering to medication schedules in general, and to eye drops in particular. Research shows that only about one-quarter of patients properly self-administer eye drops (1), with about half of patients wasting multiple drops before successfully instilling one in the eye or unknowingly missing their eye completely (2). Some patients may lack dexterity or the cognitive ability to remember and instill drops correctly. Skill with drop instillation may be even more limited for perioperative patients who are unaccustomed to using eye drops.

There are several steps we have taken in our practice to reduce the burden of drops and improve compliance with perioperative medications. Compounded formulas that combine the NSAID and antibiotic into a single drop can be beneficial in reducing the number of drops. Sustained release delivery is another mechanism to eliminate one of the drops altogether. For the past few years, we have been using DEXTENZA (dexamethasone ophthalmic insert) 0.4 mg, which continuously releases a self-tapering preservative-free dose of dexamethasone for up to 30 days. I typically place the insert at the conclusion of cataract surgery. It takes about 30 seconds or less to insert. I dry the area and pull down on the lower lid and use a dilator to dilate the punctum. Once the scrub nurse hands me the forceps with the insert, I quickly pull out the dilator and place the DEXTENZA insert into the canaliculus via the lower punctum. Timing of insertion is flexible; the insert can be placed before, during, or after surgery.

This approach eliminates the need for topical steroid drops, which from my perspective is the most important category to address in terms of patient compliance. Not only does it remove the most complex element of the topical medication regimen (steroid tapering demands that the frequency of topical steroid drops changes weekly), but I can also be confident that the steroid is getting to where it needs to be to effectively control inflammation and pain, and to reduce the chance of postoperative cystoid macular edema (CME).

With the intracanalicular insert, the steroid is not only delivered directly to the eye, but is consistently eluted throughout the day, rather than just at specific time points during the day. With this consistent distribution of the medication, I have seen much less rebound inflammation. I believe that the very gradual tapering of the insert is an enhancement to a topical tapering schedule, because even the most compliant patient is still experiencing a decrease in medication in large steps as they taper down from four to three drops (and so on) per day.

When possible, the insert is my preference in almost all cases. It is particularly helpful for patients who require caregiver assistance to instill drops, as I know that they will get the medication, regardless of caregiver availability.

Study results
 

A recently published study confirms my own impressions that patients strongly prefer DEXTENZA over topical steroid drops. The study evaluated early, real-world experience with the insert at 23 cataract practices by surveying patients (n=62) and practice staff (n=19) (3). Almost all the patients (93 percent) were “satisfied” – or “extremely satisfied” – with the implant and highly preferred it over topical steroid drops. This preference was based on a description of the steroid regimen and their experience with drops; there was not a cross-over or control group.

Interestingly, 42 percent of the patients had a pre-existing comorbidity that either also required drops (e.g., dry eye, glaucoma), or could make drop instillation difficult (e.g., Parkinson’s disease). As I have seen with my own patients, about 4 in 10 patients in the study reported that it was difficult to take all their eyedrops at the right time and/or that it was difficult to get the drops into their eye (3). Only 18 percent of patients reported no difficulty at all with instilling drops. About one-quarter didn’t understand that compliance could affect their surgical outcome (3).

Impact on the practice
 

Practice staff were also queried in the study and reported high levels of satisfaction with the dexamethasone insert. There was a 45 percent reduction in time spent educating patients on postoperative drop use and a 46 percent decrease in time spent addressing calls from pharmacies regarding postoperative medications. This time savings totaled an average of 15.5 minutes per patient. For the participating practices, which performed an average of 160 cataract surgeries per week, that could add up to approximately 40 hours per week, or the equivalent of a full-time staff person (3).

This validates other reports that calls from patients or pharmacies regarding drop substitutions for post-cataract surgery drops were responsible for 3,000 staff hours every year (4). I know I would rather my technicians and staff spend their time on patient care, or else on something that brings revenue into the practice, rather than adjusting, changing or confirming existing prescription orders.

It is not at all surprising to me, given the impact on patients and staff, that physicians at the same set of real-world cataract practices also reported high levels of satisfaction with the DEXTENZA insert, comfort with its insertion, and a perception that the dexamethasone insert improved patient compliance (5). The majority (62.5 percent) preferred it over traditional steroid drops, although this was not as high as the percentage of patients who preferred the insert (93 percent) (3,5).

Effective control of inflammation should always be our goal. By eliminating problems with patient compliance and poor instillation skills, a dexamethasone insert placed at the time of surgery can provide the results we desire in a manner that is highly satisfactory to patients, doctors, and practice staff.