Alternative Pharmacotherapy Paradigm to Cataract Surgery
of endophthalmitis when intracameral cefuroxime or the four antibiotic combination regimen was used was estimated to be 0.045 %. Assuming a 100 % prevention of endophthalmitis, the cost per case of endophthalmitis was estimated to be $3,793. The productivity losses caused by endophthalmitis were excluded from the cost analysis.20
Four treatment modalities (intracameral cefuroxime, subconjunctival gentamicin, subconjunctival cefazolin, and topical sulfacetamide) were associated with savings in net costs. Intracameral cefuroxime yielded a net cost savings of approximately $480,000 because of the endophthalmitis cases that were averted. When the treatment costs saved from prevented cases of endophthalmitis were excluded, the cost-effectiveness ratio of intracameral cefuroxime over no intervention was $1,403 per case of post-operative endophthalmitis prevented.20
The reasons for the persistence of steroid usage are multifactorial, but two key factors appear to be consistent over the years: unpredictability and expectation. The unpredictability of how one patient will respond to surgery compared to the next, even when the surgeon performs the same procedure on similar patients with no significant comorbidities, is a factor. Another factor is patient’s expectations—realistic or unrealistic. Patients today are better informed than patients 20 years ago and this is a direct result of technology, e.g., the computer and the Internet.
One option is to use what are termed ‘safe steroids.’ These steroids, e.g., loteprednol etabonate ophthalmic suspension, are potent, efficacious, and have fewer side effects when compared to prednisolone acetate and other potent steroids.30
The most expensive topical fluoroquinolones, e.g., gatifloxacin and moxifloxacin, needed to be at least 19 times more effective than intracameral cefuroxime to achieve a cost-effective equivalence. For all regimens, except topical sulfacetamide and subconjunctival gentamicin, the number of cases that would need to be prevented exceeded the number of cases expected without treatment (247 per 100,000 patients). Sensitivity analyses varying the cost of antibiotics, cost of endophthalmitis treatment, risk of infection, and degree of complications from intracameral injections (anaphylaxis or toxic anterior segment syndrome) confirmed the robustness of these findings. The data indicated that the use of intracameral cefuroxime was more cost-effective than that of commonly used topical antibiotics for the prevention of endophthalmitis after cataract surgery.
All the fluoroquinolones tested (ciprofloxacin, ofloxacin, moxifloxacin, or gatifloxacin) were not cost saving, even after assuming that all potential cases of endophthalmitis were averted after their use. Approximately a five-fold increase of intracameral moxifloxacin and an eight-fold increase of the least expensive topical fluoroquinolone, e.g., ciprofloxacin, were needed over intracameral cefuroxime to achieve the same cost-effectiveness ratio as it directly related to clinical effectiveness (the number of endophthalmitis cases prevented).20
Difluprednate ophthalmic emulsification 0.05 % was approved by the US Food and Drug Administration (FDA) and indicated for the treatment of inflammation and pain associated with ocular surgery. The major benefit associated with difluprednate is its twice-a-day dosing frequency. The twice-daily doses enhance therapeutic compliance. Another benefit is dose uniformity, i.e. dosing concentration, which was predictable compared to that of other topical steroids for which the drop concentrations were highly variable.32
However, reports have indicated
that the use of difluprednate is associated with significant IOP elevation and the drug is expensive.26,32,33
Topical Non-Steroidal Anti-Inflammatory Drugs Despite the advancements in technology associated with cataract surgery, inflammation will occur, e.g., iridocyclitis, and patients will complained of discomfort and photophobia. The goal of any anti-inflammatory agent is to suppress the inflammation quickly and thereby enhance recovery. Since the late 1990s, topical NSAIDs have been a mainstay of the post-operative regimen. Although the pharmacokinetic and pharmacodynamics of the various topical NSAIDs differ, it is well documented that topical NSAIDs possess both analgesic and anti-inflammatory properties35–37 associated with topical steroids.
without the side effects commonly
Topical Steroid—Indicated or Not Indicated The use of a topical steroid in the post-operative period is also under discussion. At the start of the twenty-first century, the idea that topical steroids would no longer be needed in uncomplicated cataract surgery would have been a very radical concept, if not downright inconceivable. Today, with the advancements in surgical techniques, e.g., small incision, surgical technologies (torsional phacoemulsification and femtosecond), and the more efficacious NSAIDs, the concept of ‘no steroids’ is not as radical. The complications21–26
and benefits,4,26–30 e.g.,
controlling and preventing macular edema, associated with topical steroids are well documented. The initial indication for steroid usage post cataract surgery was secondary to the inflammation. This inflammation was caused by the type of lens implanted, the quality of the lenses in the earlier years, and the methodology of extracting a cataractous lens. IOLs today are of higher quality, have better quality control during production, better surgical techniques, better surgical equipment, and require a shorter surgical time. Collectively, these factors minimize the degree of inflammation. Yet, ophthalmologists, on the whole, persist in prescribing topical steroids.
US OPHTHALMIC REVIEW
Current topical NSAIDs include ketorolac, nepafenac, and bromfenac. Studies have shown, as a class, that topical NSAIDs are efficacious in controlling post-operative inflammation in the anterior segment, give good pain control and good visual recovery (rehabilitation), and, equally important, in minimizing the incidence of cystoid macular edema in both diabetics and non-diabetics.4,36
A recent study by Duong et al.
demonstrated that NSAIDs alone were efficacious in controlling anterior segment inflammation.36
The study also demonstrated that topical
NSAIDs were equally efficacious as topical steroids in preventing the development of cystoid macular edema both, clinically and by OCT.36 One real drawback to NSAIDs is that, although all the NSAIDs are covered by insurance companies, the co-pay tier for the respective NSAIDs is dependent on the state and county the patients reside in, which can translate into a costly endeavor for patients on fixed incomes.
The Future
The future of pharmacotherapy after cataract surgery is a work-in process and open for discussion and further research. Antimicrobial prophylaxis use pre-operatively to decrease or prevent endophthalmitis
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