Cataract-intraocular lens (IOL) surgery is the most common procedure performed by ophthalmic surgeons worldwide. Currently topical administration is the most common route of ocular drug delivery during cataract surgery.
Despite its apparent easy accessibility, the eye is well protected from foreign materials and drugs by a number of very efficient mechanisms such as blinking, induced lacrimation, tear turnover, nasolacrimal drainage, which cause rapid removal of substances from the eye surface and by the cornea, which forms the physical-biological barrier.
Optometrists who are considering writing a prescription for any medicine will find that the pharmacist is a useful source of information regarding the availability of alternatives, stock outages and the availability or feasibility of a compounded product.
Compounding can be a useful adjunct to the care of some patients and patient safety should always be paramount.
In a health-care system in which the glaucoma patients and treating physicians have lost significant control over the daily battle to preserve visual function, compounding pharmacies allow both parties to gain back that control.
Doctors believe this will improve patient outcomes by reducing some of the significant barriers to medication treatment adherence. In addition, the use of compounded glaucoma regimens improves daily satisfaction among patients, office staff and physicians within the world of glaucoma medical treatment.
Cost and confusion over medications are two commonly cited reason for patient non-adherence after surgery. These factors can negatively affect the postoperative course, cause anxiety and frustration in patients and increase the time staff spends on the phone.
As a high-volume refractive lens and laser vision correction practice, ophthalmologists knew that they needed to find a solution to postop medication issues. It needed to be safe, cost-effective and, ideally, simple. Using compounded medications has met all three requirements.
Endophthalmitis is one of the worst complications for any IOL procedure. As such, doctors wanted to decrease the risk as much as possible.
Given the impressive data on using intracameral antibiotics to decrease that risk, they now use either intracameral moxifloxacin or cefuroxime in every case (examples of that data are from Haripriya et al, Ophthalmology, 2016; Haripriya et al, Ophthalmology, 2017; and Haripriya et al, Journal of Cataract & Refractive Surgery, 2019).
Doctors also wanted to make sure that each patient was able to get an antibiotic, steroid and NSAID postoperatively without each medication diluting the other. While there are many compounding pharmacies, they have successfully used three in the last few years; OSRX, Imprimis and Leiters.
Although it could be argued that preoperative betadine and intraoperative intracameral antibiotic is sufficient, ophthalmologists felt that it was still prudent to continue with postoperative antibiotic drops as well.
Thankfully, given the advent of easily accessible compounded medications, this adds minimal cost and no additional difficulty for the patient. Formulations that include combinations of moxifloxacin, gatifloxacin, prednisolone acetate, dexamethasone, ketorolac and bromfenac are all readily available.
In practice, doctors are now most commonly using prednisolone acetate/gatifloxacin/bromfenac four times a day in each eye for 1 week. They then use prednisolone acetate/bromfenac as a taper over 3 more weeks.
With this regimen, they have found an even lower rate of rebound iritis than they did with separate branded drops, most likely due to improved compliance.
For many patients, laser vision correction (LVC) is their first medical procedure. This is exciting yet can also be anxiety-provoking. As such, ophthalmologists wanted to make the process especially simple and cost-effective for these younger patients.
Prior to new system, they provided a prescription that patients would pick up and have ready the day of the procedure. Unfortunately, with rising costs of medications, increasing co-pays and variabilities among pharmacies, it was not uncommon for patients to show up to surgery without medications or to call the office asking for different, less costly (and effective) options.
Thankfully, the advent of safe and cost-effective compounded medications again provided with a solution. Doctors wanted to take customer service to a new level, however.
Although it is common for practices to charge separately for the medications, whether compounded or not if dispensed in the office, they felt this was more of a “cafeteria approach” rather than a patient-centric “palatable pricing approach.”
Given their goal of making the process simple and cost-effective for young patients, doctors now just include compounded medications in the global fee for LVC procedures and dispense at the time of surgery.
With this new system, patients now rarely call our office for LVC medication or cost-related questions, which saves technicians and front desk staff countless hours.
In addition, doctors are now almost always able to use their preferred regimen of moxifloxacin or gatifloxacin with prednisolone acetate four times a day for a week in LASIK and SMILE rather than sometimes having to resort to other regimens.
Safe and cost-effective compounded medications have been a game changer in practice — for doctors and patients. Gone are the days of irritated, pharmacy-related phone calls and significant medication non-compliance. With more options available every year, patients and practices have a win-win in compounded medications.