Article

How to incorporate intraoperative drugs

These drugs may reduce the postoperative eyedrop burden, but they require changes to communication and workflow.

In recent years, a number of ophthalmic medications have become available for administration in the operating room, rather than as topical medications in the postoperative period.

Postop medications can have an outsized influence on patient satisfaction and healing. Indeed, our practice recently conducted a study of patients who were followed for 3 months after cataract surgery. Those who achieved their desired visual outcome and were pleased overall were asked to identify the most difficult part of the process. For the overwhelming majority, it was the postoperative drop regimen, which can be at least partially avoided with intraoperative medications.

Beyond increased satisfaction, some patients may have medical conditions that affect dexterity and/or memory that make adhering to the postoperative drop regimen especially difficult. In those cases, the use of intraoperative alternatives can make a big difference.

In addition to their impact on patients, postoperative medications also challenge the staff who manage call-backs and insurance paperwork. Another study we conducted found that, from the postop day-1 visit, the use of dexamethasone intraocular suspension 9% (DEXYCU, EyePoint Pharmaceuticals) or dexamethasone ophthalmic insert 0.4 mg (DEXTENZA, Ocular Therapeutix) saved more than 5 minutes per patient per technician in call-backs and reminders compared with traditional steroid drops. Because postoperative steroid drops are administered multiple times per day, usually on a tapering schedule, we find that we get the most call-backs about this element of the regimen.

As the use of intraoperative options becomes more widespread, it is important for the whole practice team to understand what they are for, how they can help, and the practical adjustments needed to make best use of them.

Novel intraoperative medications

In 2019, two new sustained-release formulations of dexamethasone became available for the treatment of inflammation after ocular surgery. DEXYCU is an intraocular steroid repository that is administered at the end of cataract surgery. It gradually releases dexamethasone directly to the inflamed tissues within the eye for the first few weeks after surgery.1 DEXTENZA is inserted immediately after surgery into the canaliculus of the lower or upper eyelid. It releases dexamethasone onto the ocular surface for the first month postoperatively.2 It is expected that most patients treated with either of these medications will be able to forego the conventional postoperative topical steroid, greatly simplifying the medication regimen.

Another relatively recent intraoperative medication, phenylephrine 1%/ketorolac 0.3% intraocular solution (OMIDRIA, Omeros); is used to maintain pupil dilation during cataract surgery; because it contains a non-steroidal anti-inflammatory drug (NSAID), ketorolac, it likewise has the potential to aid in replacing a portion of the postoperative medication regimen.3

In addition to these FDA-approved options, ophthalmic medications for intraocular use have been formulated by compounding pharmacies, including Leiters and Imprimis Pharmaceuticals, which offers “Dropless” injectable formulations.4 Compounded products may combine anti-inflammatory and antibiotic drugs and can be especially useful in cases where poor adherence to the postoperative regimen is likely.

In addition to making life easier for patients, intraoperative medications offer surgeons a greater degree of control over postoperative healing and can also lessen the administrative burdens on staff in the form of call-backs. Here are some of the ways our practice has found to make incorporating these newer options successful.

Communication strategies

At our practice, setting patients up for a great experience with cataract surgery starts with their very first interaction at the front desk, where we provide a brief handout explaining the procedure itself. Moving on to biometry and every other touchpoint in the preop visit, technicians, nurses, and staff can help provide information about cataract surgery as well as a sense of enthusiasm and confidence. Technicians start the discussion of patients’ desired outcomes and expectations and elicit helpful details about patients’ lifestyles.

At our practice, we also have a full-time employee dedicated to educating patients on pre- and postop medications. This technician follows the doctor’s preferred regimen and, if substitution is necessary, is aware of what the doctor generally feels comfortable substituting. We have trained this technician to understand the various factors that can affect postop healing, including patient adherence to the regimen, consistency of a drop’s vehicle, etc. They are aware that many companies make generic alternatives and the vehicle can play a significant role in the stability, bioavailability, and tolerability of the active medication. Our educators and technicians know that surgeons try to control all possible aspects of the surgical process and want as little variability as possible, therefore, the same philosophy applies during the postop period.

By the time I see a patient, they have been prepared by multiple members of the practice team and have encountered handouts and videos in the waiting room. I also have a surgical liaison who follows me between office locations and provides follow-up information and guidance directly after I speak with a patient. In my conversations, I focus on patients’ goals after surgery and try to set appropriate expectations around the visual acuity they may be able to achieve.

With regard to perioperative medications generally, I explain the differences between brand-name and generic topical drops and provide a handout that includes my rationale for selecting the medications I recommend (see “Consider handouts,” below). In cases where I am going to use DEXYCU or DEXTENZA, I say, for example, “I’m going to place a medication at the time of surgery that will help reduce the number of eyedrops you have to use after surgery.”

Consider handouts

Printed handouts provide reminders to patients and reinforce messages given in conversation by the doctor and practice team.

  • Branded vs. generic medications. Our practice has prepared a handout that clearly explains the differences between brand-name and generic ophthalmic medications, highlighting the fact that differences in manufacturers and inactive ingredients can have an effect on the drop’s efficacy.
  • Postoperative drop schedule. We use this handout to give patients an at-a-glance reference for their drop schedules for each week. We include a variety of possible options on the sheet and circle the ones that apply to each individual patient.
  • Intraoperative drug-specific explainers. In some cases, manufacturers of intraoperative ophthalmic drugs offer downloadable, printable patient information sheets on their websites.

As for what to expect postoperatively, with DEXYCU I let patients know that while the drug typically remains in place behind the iris, there is a chance they may see the medication as a small white dot in the eye when they look in the mirror; this is no cause for concern and should resolve as the medication elutes. With DEXTENZA, I tell the patients that they may feel a bit of pressure during the insertion of the product but should not feel much irritation or pain. Since OMIDRIA is a transient medication used during surgery, there is not much to say about postoperative expectations; however, we mention to patients that we give this medication to reduce inflammation and provide a more stable environment during surgery. We use compounded topical postop drops in patients whose insurance does not cover the drug delivery products and/or the brand-name topical drops. There is a value to the simplicity of the compounded drops, especially for those who have difficulty with memory or physical dexterity.

I also inform patients of the small chance that we may need to add another medication if there is excess inflammation postoperatively. But, for the most part, use of one of these intraoperative medications should mean one fewer drop for them to worry about.

Workflow and insurance considerations

DEXYCU, DEXTENZA, and OMIDRIA all currently have pass-through status, which means that Medicare reimburses the cost of the drug to the facility. Still, there are some nuances. It is crucial in all cases, particularly for patients with Medicare Advantage or other commercial plans, for staff to verify coverage in advance and avoid surprises. The manufacturers of these drugs have many resources that can assist with determining coverage and pre-certifications. Our staff has relied heavily on these companies’ support staff to help with eligibility questions. These teams can make the process more streamlined in general and can even provide me with information to support my rationale for including these medications on the formulary.

While this is a change in routine compared with topical drops, doing this work on the front-end can save time in questions and call-backs after surgery. Our practice found that the adjustments (simplifying the postop instructions, reducing calls from the pharmacy and patients) saved more than 5 minutes per patient per technician. For a surgeon performing 15 to 20 cases in a given day, imagine how many hours can be saved by decreasing just one postop medication.

As a corollary, knowing in advance which patients are eligible and planned to receive one of these intraoperative drugs is essential because it impacts the prescriptions they need to have filled prior to surgery. We want to avoid situations in which a patient either does not receive one of these medications at the time of surgery and needs to scramble to get postop drops or a patient fills a prescription for topical steroid ahead of time but is treated with one of these intraoperative drugs instead.

Each practice will have to establish a flow of communication that works within their existing processes, but however this is accomplished, making sure the surgeon, staff, surgical coordinators, and technicians are all on the same page about a patient’s drug regimen is key. Putting a process in place helps ensure that patient instructions about the postoperative routine are correct and consistent and reduces the likelihood of a patient getting a superfluous topical steroid or, worse, no steroid at all.

Involve the full practice team

Successfully introducing any new product or procedure into the practice requires each member of the practice team to be involved and take ownership of their parts of the process. With a little bit of effort at the outset, intraoperative ophthalmic medications can be integrated into existing practice workflows and benefit patients, surgeons, and staff. OP

REFERENCES

  1. Donnenfeld E, Holland E. Dexamethasone intracameral drug-delivery suspension for inflammation associated with cataract surgery: a randomized, placebo-controlled, phase III trial. Ophthalmology. 2018;125(6):799-806.
  2. Tyson SL, Bafna S, Gira JP, et al. Multicenter randomized phase 3 study of a sustained-release intracanalicular dexamethasone insert for treatment of ocular inflammation and pain after cataract surgery. J Cataract Refract Surg. 2019;45(2):204-212.
  3. Donnenfeld ED, Whitaker JS, Jackson MA, Wittpenn J. Intracameral ketorolac and phenylephrine effect on intraoperative pupil diameter and postoperative pain in cataract surgery. J Cataract Refract Surg. 2017;43(5):597-605.
  4. Lindstrom RL, Galloway MS, Grzybowski A, T Liegner J. Dropless cataract surgery: an overview. Curr Pharm Des. 2017;23(4):558-564.