In the United States we perform more than 3 million cataract surgeries per year and that means millions of postoperative eye drop prescriptions. With declining reimbursements of surgeon fees and increasing costs of medications, are we getting to the tipping point? Depending on the specific medications prescribed, the retail cost of the eye drops can be more than the surgeon fee for patients enrolled in Medicare.
The retail price of eyedrops has increased dramatically over the past decade and that includes both brand-name as well as generic medications. I have noted some generic corticosteroids like prednisolone acetate costing $100 per bottle. Brand-name corticosteroids often can be twice that price. And when we look at NSAIDs, hold on to your seat—some of them have retail prices in excess of $300 for just a couple of milliliters!
If I had cataract surgery on my own eyes tomorrow, I would want to use an antibiotic, a corticosteroid, and an NSAID perioperatively. But are there other options? Do we need to prescribe all of these medications for every patient? Is there a lower-cost option that is still efficacious?
Studies have shown that use of intracameral antibiotics is helpful in preventing the rare but sight-threatening complication of endophthalmitis. Large studies have looked at using a small dose of intracameral cefuroxime or moxifloxacin at the time of surgery with excellent results. These studies are so convincing that I heed the advice in my own private practice and my partners also follow suit in our surgery center. With this intracameral antibiotic in the eye, do we need to use topical antibiotics for a week or longer in the postoperative period? The argument for “yes” is because of the sometimes-vague concept of “standard of care in the community.” However, remember that at one time the standard of the care in the community was to avoid inserting intraocular lenses and to avoid phacoemulsification.
The idea of placing medications in the eye to avoid having to use postoperative drops is not new and it can be helpful. Depot injections of corticosteroids or antibiotics have been done for decades and now these are available commercially in a premixed format ready for use. These medications are injected behind the zonular structure and into the vitreous where they have an effect for a few weeks. The side effect is a cloud of mediation floating in the vision in the postoperative period. Also, if the patient has an increased intraocular pressure from the corticosteroids, it is not easy to take away the depot of medicine.
Compounding pharmacies are also offering combination drops that are not otherwise commercially available, putting a steroid, NSAID, and antibiotic in 1 bottle for a more reasonable price. This sounds like a good option, though a high level of trust in the sterility and processing at the compounding pharmacy is needed.
At the time of surgery, small aliquots of preservative-free moxifloxacin and triamcinolone could be placed in the anterior chamber, thereby providing immediate antibiotic coverage at the most critical time and also giving immediate anti-inflammatory activity. Due to the high turnover of aqueous humor, the antibiotic may only last a few hours—although the triamcinolone particles would last a few days because these particles tend to embed into iris tissue. For continued postoperative inflammation suppression, a combination of a topical corticosteroid and NSAID could then be delivered for a few weeks. The total cost of this regimen would come in at about $100 per eye at current prices. And more importantly, this is a regimen that I would happily accept for my own cataract surgery sometime in the future, assuming there was reasonable evidence that it was safe and effective.
I’m all for a free market and the pharmaceutical companies are of course welcome to price their medications as high as they want. But as physicians, we guide patients; and we should not feel tied to any single product if other great options exist.