Managing Inflammation in Refractive Cataract Surgery with Dr. Mitch Jackson and Dr. Darrell White

In this video from Interventional Mindset, Mitch Jackson, MD, and Darrell White, MD, discuss pre-, intra-, and post-operative strategies for both cataract and refractive surgery.

With a combined six decades of refractive and cataract surgery experience, Mitch Jackson, MD, and Darrell E. White, MD, have seen a plethora of innovations, both in technology and pharmaceuticals. Each has honed their pre-operative and post-operative protocols incorporating these advancements to ensure optimal results for their patients. In this article, they share their preferred current approaches.

Across the board, with both cataract and refractive surgery, Dr. Jackson has chosen to only prescribe brand name topical drops in his treatment regimen, refusing to jeopardize outcomes with an unpredictable generic substitute. He has found branded drops to have more consistency to the formulation, potentially lower concentration of preservatives, and offer more substantial conditioners to enhance moisturization that all tend to benefit ocular surface health.

He outlines the progression from his early days as a refractive surgeon—when both the poor quality control of drops and tendency for generic substitution created unexpected side effects upon even the most commonly performed procedures.  Fast forward to today in Dr Jackson’s professional opinion, he believes that he has access to effective and well-tolerated brand name drops that do not compromise the results.

Increased noncompliance was another issue with the subpar drops of yesteryear when dosages could be as frequent as every two hours, as opposed to today where dosing is between once or twice daily.

To ensure generics do not find their way into his surgeries, Dr. Jackson has prescriptions filled at a specialty pharmacy in many instances and asks patients to bring in the drops they are using prior to the operation to verify they are, indeed, using the brand name product.

To some degree, surgical protocols are dictated by the allowances of the surgical center where the physician is currently practicing, as different centers have variable criteria and allowances.  As an example in his current location, Dr. Jackson cannot administer intracameral antibiotics because an FDA-approved formulation is not yet available.

Using the HD Analyzer to determine objective scatter index (OSI), Dr. Jackson assesses each cataract patient to gain a subjective measurement of the density of the cataract—the denser the cataract, the higher the OSI. These results are a determinant in how to proceed in post-operative treatment.

Prior to surgery, it is imperative to make certain the ocular surface is as healthy as possible. Due to the impact of the ocular surface on the outcome of the technologies, Dr. Jackson makes certain patients are well-educated on the importance of eliminating dry eye signs and symptoms as best as possible prior to surgery. They are offered in-office thermal procedures, such as TearCare and LipiFlow, as well as appropriate pharmaceutical treatment options.

Dr. Jackson starts patients on a drop regimen 3 days prior to surgery. It involves an antibiotic drop twice a day, a non-steroidal once a day, and a steroid twice a day. Given his familiarity with using branded drops along with knowing the efficacy, this schedule has proven sufficient for his peri-operative cataract and refractive surgery management. As a bonus, this three-day window gives patients the opportunity to practice proper instillation of these eye drops, which will be critical to post-operative success.

In addition, he has patients purchase cyclopentalate eye drops to use the morning of their surgery to aid in dilation.  Upon reaching the office, the patient is not only somewhat dilated, but the appropriate eye is marked; which serves as a time-saver for all involved.

Both surgeons agree that using Omidria intra-operatively not only yields better results, but streamlines surgical efficiency. Omidria, a member of the cycloplegics/mydriatics class of drugs, is a combination of phenylephrine and ketorolac, ophthalmic non-steroidal anti-inflammatory drug (NSAID).  It  can be used alone or in conjunction with other medications intraoperatively to not only dilate the eye, but decrease inflammation and pain following ocular surgery.

Regardless of whether the IOL is monofocal or a premium upgrade (toric, presbyopia correcting, extended depth of focus, light adjusting), the same OSI system of assessment applies.

If the patient scores <2.5, Dr Jackson elect to use Dextenza (Ocular Therapeutix).  As an intracanalicular insert, Dextenza can deliver a tapered dose of dexamethasone over the course of 30 days to reduce ocular inflammation and alleviate pain, thus replacing the need for a stringent post-op steroid eye drop regimen. At the end of the month-long course of treatment, Dextenza resorbs, exiting the nasolacrimal system.

For individuals with an OSI of >2.5 (more dense cataract), Dexycu (EyePoint Pharmaceuticals) is preferred by Dr Jackson. At the end of the cataract surgery, Dexycu (dexamethasone intraocular suspension) 9% is injected into the eye. As a corticosteroid, it treats inflammation and manages pain.

In addition, a lubricating antibiotic ointment is applied to the eye post surgery and a protective shield is placed over the eye. If the patient received a light adjustable lens, the traditional shield is replaced with UV-protective goggles.

If the patient did not receive Dextenza or Dexycu, does not have cystoid macular edema, and is not considered high-risk, Dr. Jackson prescribes a NSAID to be used once per day for one month in combination with a steroid drop to be used twice a day for one to two weeks coupled with an topical antibiotic medication twice a day for a week. For more advanced or complicated cases, he may increase the dosage of a branded steroid drop. Patients who have received Dextenza or Dexycu typically do not receive a steroid, except in the case of breakthrough pain.

The doctors differ in their post-operative use of steroids, with Dr. White only prescribing post-operative steroids in cases of smoldering dry eye.

Even with the use of Omidria, Dr. Jackson chooses to dose an NSAID drop once per day for a month.

As premium IOLs are documented to be sensitive to a greater degree of post-operative dryness, the surgeons are more aggressive in treating DED in both surgical preparation and follow-up. Prior to surgery, in-office dry eye or MGD treatment might be recommended. For example, including a thermal procedure in the pre-surgical plan for all patients receiving a light adjustable lens.

Post-operatively for individuals who would like to have more spectacle independence and are willing to pay out-of-pocket for a premium IOL, Dr. Jackson prefers to utilize Dextenza, insurance permitting. He feels the drug’s extraocular benefits to the surface are even more valuable than its intraocular benefits. There will also be a more strict schedule for immunomodulators in patients who present with moderate plus level DED..

Patients who need a clear corneal surface to get the most accurate biometry, such as a premium IOL patient, will often be put on a steroid regimen. Treating their DED prior surgery will boost satisfaction, and abate concerns post operatively like worsening of DED.

Every so often, enhancement of residual refractive error is needed post op.  Currently, Dr. Jackson performs Photorefractive Keratectomy (PRK) and Laser Assisted In Situ Keratomileusis (LASIK) in these patients. Over the years, he has cycled through several different offerings for pain and inflammation post PRK, including gabapentin, neurontin, dilute anesthetic drops, and/or punctal plugs for post-operative treatment. Now, the biggest difference in his routine post-op PRK and post-op LASIK is the use of non-steroidal drops.

At present, with PRK, Dr. Jackson utilizes a bandage contact lens along with antibiotic and non-steroidal drops each dosed at twice daily along with topical steroid medication until the patient is re-epithelialized. After the bandage contact lens is removed, he continues with a branded steroid drop for 3 weeks in concert with an immunomodulator containing cyclosporine and aggressive lubrication.

With PRK, Dr. White still stays with the traditional longer tapering dose of steroids to achieve a more predictable result.

With LASIK, Dr. Jackson opts to forgo the non-steroidal drop, but still uses a topical antibiotic medication for one week, aggressive lubrication, and a steroid drop—only once the flap is down. Additionally, he prescribes cyclosporine for 3 to 6 months post-op.

Of note, anterior surface procedures such as PRK reduce the risk of dry eye among patients post-operatively, as opposed to traditional flap procedures, including LASIK. Therefore, PRK is the preferred procedure for patients with a history of or predilection for dry eye.

The surgeons concur that, in an ideal world, drops—due to cost, inconvenience, toxicity, compliance—would be a thing of the past for cataract patients, both pre-operatively and post-operatively.

Until that point, the next best scenario is drop reduction. When Dr. Jackson adds intracameral antibiotics to his standard cataract surgery protocol, he plans to move to nonsteroidal drop once a day along with some form of artificial tear lubricant to keep the ocular surface adequately moisturized. Dr. White concurred and utilizes a similar treatment regimen with his surgical patients.

From innovations in IOLs to breakthroughs in available pharmaceuticals, refractive and cataract surgery continues to advance.  As technologies evolve over time, thought leaders, like Dr. Jackson and Dr. White, will be there to proactively offer their patients the latest and most efficacious surgical solutions for their visual needs.