Ophthalmology off the Grid
Episode 1

Dropless Cataract Surgery

In the opening episode of Ophthalmology Off the Grid, Gary Wörtz, MD, invites Bill Wiley, MD, and Mark Kontos, MD, to dissect the topic of dropless cataract surgery, specifically whether the convenience of this approach is worth the risk. Dr. Wiley shares his viewpoint on why physicians should adopt this regimen and explains specific benefits that he has seen in his practice. Dr. Kontos offers a different perspective, shedding light on potential complications that could arise by going dropless.

Speaker 1: Ophthalmology off the Grid is supported in part by Beye.com, a new product listing website for the eye care community. Beye.com contains over 800 product listing pages with in-depth specs, high-res images, video demonstrations, unbiased user reviews, the option to purchase products, and more. Find us on the web at Beye—that's B-E-Y-E—.com.

Gary: Open, outspoken, it's Ophthalmology off the Grid, an honest look at controversial topics in the field. I'm Gary Wörtz. In this episode of Ophthalmology off the Grid, I sit down with two thought leaders in our field to discuss dropless cataract surgery. During interviews with Drs. Bill Wiley and Mark Kontos, we'll discuss Imprimis' LessDrops formula, the Tri-Moxi injectable, and whether the convenience of this approach is worth the risk. Listen in, it's going to be a great episode.

This is Dr. Gary Wörtz with Ophthalmology off the Grid. Today, we have Dr. Bill Wiley, and we're going to be talking about Imprimis and the dropless and LessDrops formulations that they are putting forward. Bill, I just want to say thank you for taking a little time out of your day and having this conversation.

Just by way of background, Bill and I have known each other for quite a while. Bill is someone I really look up to when I have a clinical question or have a question about a new technology. He's someone I really trust, I really like his opinion. I thought this would be a really nice interview to talk about the real nitty-gritty when it comes to dropless and compounded formulations for postop inflammatory and antibiotic control.

Bill, with that being said, I'd just like to hear a little bit of your early impressions with Imprimis and what the dropless and LessDrops formulations have done for you and your practice.

Bill: Sure, thanks, Gary. Thanks for having me. In general, I think the Imprimis dropless formula has been a great thing for our practice. About 6 months ago, as we all have seen, the current commercially available drops have become sort of an issue with our patients. Number one, we've seen drastic increases in price. Drops seem to double in price almost every few years. Not only is it expensive, but also the inconvenience of taking multiple drops throughout a cataract, let's say, regimen, postoperatively can be challenging for certain patients.

We started to see that there was a breaking point where that became a barrier to entry for cataract surgery, that some patients were saying, "I can't afford the drops," or "I don't like taking drops. I'll just hold off on my cataract surgery." I think our practice, but also a lot of practices in general around the country, wanted another alternative for their postoperative regimen for cataract surgery.

Imprimis came in at a perfect time with their solution. They've got this dropless technique where we're injecting or placing inside the eye, at the time of cataract surgery, the two most common medications: a steroid and an antibiotic to cover for antibiotic prophylaxis, but also steroid or anti-inflammatory prophylaxis, that's the Tri-Moxi, triamcinolone moxifloxacin, injectable medication for the dropless technique.

Our practice started that back in September, and we've had great success. We went all in, and every patient in our practice gets that at the time of cataract surgery. Our technique is we go pars plana injection right at the end of the case, where we place .2 mL of a Tri-Moxi solution. Right now, we're still adding a drop once a day for about 1 week after cataract surgery, mostly for those patients that want to have some kind of comfort level that they have something that they're doing to help in their healing process.

We're using Maxitrol, which is a relatively affordable and easy drop for patients to get that's over the counter. It's around $10 or $20. It's easy for the patients to get. They're getting the Tri-Moxi at the time of surgery that lasts for about a month and with their drops that they're taking, they use that for about a week and then stop. So far, it's been a huge success for our practice in a number of ways. We've seen that our callbacks to our surgery schedulers have decreased dramatically.

With commercially available drops, there's a lot of confusion: which drops, how often, when to take them, the expense, and is it covered or not covered. Right now, we have a very simple and easy protocol for patients to take after cataract surgery, and it's really just helped streamline us.

Gary: Wow, I think you've touched on some really significant points. I agree with you, Imprimis really came in at a time when we have all had enough with some of the prescription games that are played and the expense. I'll tell you, from my perspective, we spend an inordinate amount of time trying to educate our patients about the number of drops that they're going to be taking and the regimen.

Also, not only that, we have a pretty wide referral network. We have to not only make sure that the patient understands their drop regimen and that their family or caregiver understands the drop regimen and that they actually get the drops that we try to prescribe for them, which so frequently gets changed, we also have to make sure that our referral network is on board and if there's comanagement going on, that they're checking and making sure that compliance is to our standard.

I totally agree that there needs to be a different solution for our cataract patients. A simple and cost-effective solution like Imprimis just makes all the sense in the world for ophthalmologists. I think that we're seeing a tremendous amount of buzz, just when we're talking to friends and other colleagues, about this product.

Just quickly, some of the concerns or at least theoretical concerns that I've heard from other folks and maybe things I've even had questions myself. You've mentioned that you're giving this to every patient. What about those patients with glaucoma or someone who may be a known steroid responder? Have you had anybody that you would disqualify? It sounds like you're really having success with all patients, but what would you say to another doc who said, "I've got a high percentage of glaucoma patients. Am I going to be okay using it?" What would you say to that?

Bill: Yeah, great question. I probably should qualify when I say I'm giving it to every patient. There are some patients we decided may not be a candidate for dropless or at least right now in our practice, in our hands. The one patient set is the known glaucoma patients. We've backed off on using it or use it to a lesser degree. I do have friends that are glaucoma specialists and use it freely and are very comfortable with using the dropless. I'm waiting to hear their experience and feedback.

Right now, the glaucoma patients, it's an interesting group. They're used to taking drops already, they're already on drops. It seems not to be as much as an inconvenience to take a drop a day or a couple drops a day, so to add a postop regimen to them is not a big deal. For those patients, it's a little easier to continue with our traditional technique of using drops afterwards.

With that said, our glaucoma patients, we often do a procedure called endocyclophotocoagulation or iStent. Some of those procedures can be a little bit more inflammatory, so by adding intravitreal triamcinolone can actually help with their healing response. I think it can be used and it can be safe, but you do have to be aware of the potential side effect of a steroid response and be aware of that.

Gary: Yeah, absolutely. One other concern or at least something that may be a little different from giving drops is just I've heard that patients get an increase in floaters and maybe that “wow” factor on day 1 may not be what we're all used to. Also, maybe if you have a comanagement network, getting the optometrist educated, not only the patients, but getting the optometrist educated on what to expect with this. Just, if you wouldn't mind, commenting about if you've noticed that, if there are techniques in placing the drop maybe more inferiorly. What do you think about the floaters or maybe the lack of post-op visual acuity in the early stages postop?

Bill: That's a great question, and I think it's a legitimate concern. Initially, the first few cases we did, I placed the injection superior, superior temporal. Simply, that's where I had done it back in residency when we did intravitreal kenalog injections. That's where I first placed it for this postoperative drop regimen. We did see that we'd place a large bolus of a steroid that could interfere with the visual acuity.

Quickly, we transitioned to an inferior injection, where we're injecting it right around 6 o’clock, so it stays inferior. There's some techniques where we sit the patient up quickly to keep the medicine inferior in their eye. I've also decreased the amount. Initially, I was putting .2 or .25 mL. Now, I'm a little less than .2, often .15 intravitreal. I'm placing a little bit sub-Tenon's that can also have a dropless effect and extend the effect of the anti-inflammatory and antibiotic by placing it in two different places, one intravitreal and one sub-Tenon's. There are some tricks to get around the potential of those floaters, based on where you place it, how much are you placing.

I think it also boils down to preoperative education. If you can set the expectations where it's normal to have floaters for the first 24 hours and if patients understand that and they know what they're getting into, it tends not to be a major issue or problem. In general, we use this on our premium patients, our patients that are paying cash and paying for upgrades. They're happy, and it's part of the process and it doesn't seem to affect any of our patients once it's explained and done correctly.

Gary: Yeah, and also just I would be curious and I think I know the answer, but I'd love to hear it from you, how has your staff responded to this change, where they're not necessarily having to track down prescriptions and go through a huge education process? Do you feel like they're spending less of their time on the clock explaining these instructions to patients?

Bill: Definitely, I think if we stopped the dropless technique and the injections at this point, I think we'd have a revolt. It's been a huge increase in our staff satisfaction. It's been truly amazing. I think it's also there is an added expense right now. We're absorbing that expense and paying for the medication; however, I think we're getting that back in less staff time and increased patient satisfaction. It's been a break-even on the bottom line. When you first look at it, you see this added expense, but when you really see how it affects your practice in a positive way, I do believe it pays for itself.

Gary: Yeah, it sounds like it's really adding value and that can be defined in a lot of different ways. That's really exciting. One other thing I recently read and we have talked a little bit about is that you're also doing the LessDrops for your refractive LASIK patients. I'd love to hear a little bit more about that.

Bill: Sure, yeah, after our initial experience with the cataract patients with dropless, we said, "This molecule or this combination of triamcinolone and moxifloxacin is very similar to what we use for LASIK." We asked Imprimis if we can transition that into a topical formulation for our LASIK patients. We adopted that, and we've had, again, a very similar positive response in our LASIK practice.

We've used two different formulations, and we're still trying to determine if there's some advantage with one compared to the other, but we have a Pred-Moxi and Tri-Moxi LessDrops formulation. Those are the same two medications that we use for LASIK in general, but typically it's done in two different commercial drops. Now we have one combination drop.

What it's allowed us to do is decrease those LASIK drops by functionally 50%. Instead of taking two drops every time, they're only taking one drop. Also, it's made it much simpler, we order the drops for the day of surgery. The patients come in, have their surgery, we send them home with a kit that has their drops in their kit, so they don't have to worry about going to the pharmacy and that expense or an added inconvenience for them.

Also, the same sort of things that happen with our cataract patients. We had a lot of pharmacy callbacks, requests for a substitution for generic for switching a noncoverage or expense in drops that left our staff answering multiple questions, making the patients sometimes very frustrated. They're spending a few thousand dollars for a premium procedure and then are stuck with another add-on bill with an expense of a pharmaceutical medication. We had some patients just cancel over that. By now providing that drop for them, it's increased the value of the procedure and made it more simple.

Gary: Bill, how are you dosing that, typically? Also, one other question, are you doing LASIK and PRK or simply LASIK patients?

Bill: We've done both LASIK and PRK with this medication. Right now, we're dosing it four times a day for about a week. Then, after 1 week, sometimes we just stop or if they have some inflammation or some flap edema, we'll continue that twice a day for an additional week.

Gary: Excellent, Bill, it's been just a pleasure to talk to you about this. I really love hearing your perspectives on it. You always give me really good advice, and I know it comes from clinical experience, which there's no substitute for that. I think we're all just really excited for Imprimis. We're all excited for the solutions they're providing. They're meeting an unmet need and our patients and our staff, and I think a lot of doctors are really just happy that we now have this new advantage, this new solution, which kind of plagued us for a while. Bill, I just want to say thank you.

Bill: Thanks, Gary.

Gary: It's awesome.

Bill: It's been great.

Gary: Thanks. Bill provides many great arguments for adopting a dropless regimen, but I want to take a look at this from the opposite side of the spectrum. What are the arguments for not using this technology? I sat down with Dr. Mark Kontos to hear his differing opinions on the topic.

Today, I have with me Dr. Mark Kontos. Mark, I just want to say thank you for taking a little bit of time and talking to me about your practice and some interesting topics that we've already discussed and we will get into a little bit further here. I just want to say thank you for coming in.

Mark: My pleasure, Gary. It's a lot of fun to be here with you. I really think this is a great idea and looking forward to all the things you're going to be doing with it.

Gary: The idea of this is really just to have honest conversations, just like we would on the phone or consulting in a meeting, but having it recorded for other ophthalmologists who may be driving the car or just interested to hear what fellow surgeons would think about an interesting topic.

Something that we were just talking about last night would be just the whole concept of dropless cataract surgery. This has been a really hot topic for good reason. I think that eye drops probably are one of the most painful, from an administrative to prescribing to educating, it's just a very annoying process trying to get patients educated on their eye drop schedule, whether that's after LASIK or after cataract surgery.

It's a very confusing topic, and so obviously it's very appealing to have an opportunity and an option to give them all the medicine they need at the end of their cataract surgery, for example, and at that point, not have to really worry about the education side of things and compliance. You're really taking that responsibility off the patient's shoulders.

As you've looked at this, and you've I'm sure looked at lots of different new techniques over your career, give me your first impressions and maybe as you've thought about maybe implementing this, what you decided and why you decided that.

Mark: Yeah, it is an interesting thing. I would say that probably in our practice, if we look at the phone calls that we field after hours, I would say the bulk of them are related to postoperative or preoperative drop regimen questions about, "The pharmacy this," or "I didn't get that," or "What am I supposed to do with this? I don't remember," or whatever it happens to be.

The idea of being able to eliminate all of that and not have to deal with all of the things that all those mean, who wouldn't be attracted to that idea as a surgeon? Of course you would be, and I certainly was. A dropless cataract, that's a great thing. I'd love that. Then, as you start actually looking at it and then when you start peeling back the layers of this and then you go beyond just that phrase, then it becomes a little bit more of not such a clear picture, really, and for a few different reasons.

When we started looking at that, I've taken a very conservative approach in that regard. Number one, there's reasons to give patients eye drops before surgery. Really, you can argue standard of care issues and stuff, but there are certain patients, maybe a diabetic patient who got macular CME on their first eye, you might want to give them a little pretreatment, so there's patients that maybe need drops before surgery.

Then, after surgery, there's some issues. There's things that can come up with using this regimen, the dropless surgery regimen that's out there right now. One of them for me was is that the people that I thought that would be most interested in something like this are my premium cataract surgery patients, the patients who are picking a premium IOL. The way it actually works for these patients, dropless, of course you have that big bolus of steroid in the vitreous that you got to deal with. All of a sudden, the next day, there's this big cloudy vision issue that patients are describing.

I love the idea of having patients come in the next day and just be wowed by how they're doing, "I haven't been able to read like this” for whatever. A lot of that goes away when you're talking with people who are doing this. You have to educate them, so it's another thing you got to educate them on. That's a negative, I think. There's issues like that, a pressure spike, that sometimes there can be pain involved with doing this and some other stuff. To me, there's some of those issues.

I think there's some things, the concept is great, but it's like a lot of concepts, it's maybe not quite where it needs to be to be the concept that we really think of it to be.

Gary: Sure, and we went through that same process of trying to figure out, "Is this something that we want to adapt?" In my practice, it's a very referral-heavy practice, where we're relying on other docs to do some of the postop care. We work with great doctors, and we're really proud of our network, but the reality is you don't want to push off any headaches or problems on the docs who are providing postoperative care.

If you have, let's say that this works 95% of the time, and I think talking to some colleagues, you're probably looking at maybe 10% to 20% of people might need some sort of breakthrough coverage with steroid, I think that's pretty accepted that dropless is going to be able to cover the vast majority of your patients for cataract surgery. There's always going to be those few patients who may need an additional steroid drop, etc.

The reality is, at that point, you've done something for the patient and they still need to take drops or if they have an adverse event, even if it's totally unrelated to the intravitreal or the transzonular delivery of the medicine, you're taking the risk from the patient's compliance side of the equation, whether they're going to fill their prescription and take the eye drops.

You've taken that risk and are putting it on your side of the equation and you're giving them a medicine, obviously trying to help them, but there's this adage that says, "No good deed goes unpunished." If you have an adverse outcome, even if you could argue that it wasn't related to that, it could be looked at that you were doing something and because of that, if they got a retinal detachment or a pressure spike, that you did something that caused them harm.

For me, that's one thing I didn't necessarily want to take on when trying to do something nice and helpful for a patient. I wasn't really comfortable with that.

Mark: The question really is, “Is it worth it? Is the convenience worth it?” The answer for me right now is there probably can come a time when it is, but I don't know if this is the version that is.

Gary: We came to a similar conclusion, but as we were going through that discussion, Imprimis came out with this really great solution, which is called LessDrops. For us, we just felt like that was the real solution we were looking for. LessDrops basically is a compounded prednisolone-moxifloxacin, and you can also get that with ketorolac added as well. It's one drop, it's all in one bottle, and they can make the volume that you want and it's provided at a low cost.

What we're doing is we've eliminated all the variability. If you prescribe someone Pred Forte, there's about a 1% chance they're going the actual Pred Forte. They could be substituted FML or Lotemax or they could get a generic Pred, which is pretty common, but you just don't end up knowing what they're on.

By having all of that control brought in-house, we have really eliminated all those phone calls and we get a volume that's more than sufficient to treat them for their entire course. We say, "This is one bottle,” and we have our patients take it four times a day for the first 2 weeks, two times a day the third week and one time a day for the fourth week. We obviously titrate that per patient; if they're going to be a little more inflamed, then we're going to up that.

That's been a really nice starting regimen. Our optometrists have loved it because it's such a simple regimen. They are immediately recognizing it's easier, the patients understand it. We are charging the patient for this, and it's not covered by their insurance, but it's provided at such a low cost that it's typically more affordable than even their copays would be. We really have not gotten much at all, really no, pushback from patients.

This has been one of those changes where, anytime you're in a practice, it's a well-oiled machine and changing one thing, even if it seems really simple, you don't know how that's going to affect the other dominoes that fall. I will say that, in our practice, implementing this has been just a dream, and it's really been a win-win-win on every front.

Even though our practice didn't come down on the dropless side of the equation, we have found so much success and we're so happy that we've found the LessDrops. It just really seems like the low-hanging fruit, where we're still giving the patients the responsibility of taking the drops, but we're making it really easy for them to comply.

Mark: Yeah, I think that's a good example of where you can look at a thing and say, "Okay, this is what we're trying to get to. This isn't the solution, but maybe this is an interim step that can get me through or make it better than what it has been in the past,” and this is a better solution, you're right.

The cost issue, I think is a good point. A lot of patients are so clued in to the expense of their medications and that sort of thing. If you can explain to them, "Hey, look, you're actually going to save money by doing this, and it's going to be a lot easier," that's difficult to not have that be a positive experience.

Gary: Yeah, absolutely. My patients, this is something I didn't really anticipate, but they actually feel like we are giving them something that's special because we actually have had this formulated for them for cataract surgery. The patients really feel confident that they're on exactly what their doctor wants them to be on. I think it's actually helped compliance to know, "All right, I got this medicine from my doctor at their office and this is how I'm supposed to take it." They really feel comfortable that they're getting what they're supposed to be getting.

Mark: Yeah, I think it's a great idea. I think it's something that we should probably take a look at that. It might be something we might want to get going on.

Gary: Sure, and Imprimis has been really easy to work with. I can tell you, they're a great company that has provided us a really nice solution, and we're very happy to work with them.

Mark: Yeah, it looks good.

Gary: Thanks for listening to this episode of Ophthalmology off the Grid. Like what you hear? Stay tuned for more episodes available on Eyetube.net. Until next time.

Speaker 1: Ophthalmology off the Grid is supported in part by Beye.com, a new product listing website for the eye care community. Beye.com contains over 800 product listing pages with in-depth specs, high-res images, video demonstrations, unbiased user reviews, the option to purchase products, and more. Find us on the web at Beye—that's B-E-Y-E—.com.

2/22/2016 | 26:11

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