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Topical medications before and after surgery are necessary to prevent infection and inflammation, and to ensure optimal outcomes and patient satisfaction. Much of a patient’s satisfaction and happiness has to do with his or her experience with drops. The complexity of the postoperative drop regimen, however, can be incredibly confusing, as patients must administer several different drops throughout the day.
AT A GLANCE
• Many patients struggle to comply with complicated and expensive postoperative drop regimens.
• Replacing an array of different medications with complex instructions with a single, combined drop (LessDrops; Imprimis) has improved the experience for patients and our staff.
• In the spring, Imprimis plans to offer a new combined drop that replaces nepafenac with bromfenac, which offers good absorption and is well tolerated.
Many patients already struggle with compliance1,2 because of complicated regimens, inexperience, health, busy schedules, and frustration. Some require assistance from family or friends, creating an additional obstacle. We have found that even patients who are actively attempting to correctly follow instructions have issues due to the sheer complexity of what is required.
Introducing LessDrops (Imprimis Pharmaceuticals) into our practice has significantly decreased these problems. Replacing an array of medications and their complex instructions with a single, combined drop has simplified the postoperative regimen and improved the surgical experience for our patients and staff. We had one patient who was so happy that she cried—not because her vision had been improved to 20/20, but because her experience with LessDrops had been such an improvement over the drop routine she had followed after surgery in her other eye.
Implementing LessDrops into our practice was simple. Our technicians and office staff were eager for the change, as they knew that eliminating the hassle associated with a complex drop regimen would reduce the time spent on problems and streamline the entire process from preoperative preparations through postoperative follow-up and care.
The cost of traditional drop regimens has created concerns. The medications, although effective, can be expensive even when covered by insurance. Many patients are on fixed incomes, and premium patients look to reduce costs wherever possible. With the new routine, we can order and pay for the medications through Imprimis and recoup our cost from the patient. Patients can check the pricing through their insurance first, however, they commonly find that the cost of the 3-in-1 drop is less compared to the several hundred dollars individual drops can cost (Figure).
We may consider including LessDrops into a premium package to simplify the regimen and therefore help maximize patients’ satisfaction throughout the entire surgical process.
SAFETY AND EFFECTIVENESS
As is typical with all new innovations, physicians may be hesitant to adopt the LessDrops option. Some may equate the lesser price with generic quality. Although these drops may be less expensive than their brand name counterparts, they are no less effective or safe as might be the case with generics. In fact, we have much greater confidence in these products than we would in a generic alternative. We are typically a proponent of branded medications because there is no guarantee of consistency with generic drugs. Imprimis, however, meets the rigorous standards set by the FDA.3,4 They voluntarily registered to be an outsourcing facility under Section 503B of the regulatory laws of the Food, Drug, and Cosmetic Act.5 As such, their regulated compounding facilities and products are registered with the FDA and subject to regular inspections.5 This guarantees that, unlike generic companies, Imprimis is consistent with its sources and treatment of the drops’ inactive ingredients. This is significant as much of the safety and viability of a drop is based on its inactive ingredients such as pH, buffering points, the solution, and the bottle itself.6,7 To ensure correct dosing, Imprimis uses a patented surfactant solubilizing process technology to ensure that the drugs remain combined and equally distributed in the bottle.
Imprimis has developed several new formulations, some of which we are currently using. The LessDrops formulation has changed from the original combination of Pred-Moxi-Ketor (prednisolone acetate, moxifloxacin hydrochloride, and ketorolac) to Pred-Gati-Nepaf (prednisolone acetate, gatifloxacin, and nepafenac). In our experience, nepafenac stings less than ketorolac, which is a welcome improvement for our patients. We are looking forward to a Pred-Gati-Brom (prednisolone acetate, gatifloxacin, and bromfenac) combination; bromfenac has good absorption in the eye,8 and we have found it to be well tolerated.
1. Patel SC, Spaeth GL. Compliance in patients prescribed eye drops for glaucoma. Ophthalmic Surg. 1995;26(3):233-236.
2. An JA, Kasner O, Samek DA, Levesque V. Evaluation of eye drop administration by inexperienced patients after cataract surgery. J Cataract Refract Surg. 2014;40(11):1857-1861.
3. Drug Quality and Security Act. (2013, November 27). https://www.gpo.gov/fdsys/pkg/PLAW-113publ54/pdf/PLAW-113publ54.pdf. Accessed March 8, 2017.
4. Taylor, P. (2013, October 2). US bill sets 10-year deadline for pack-level tracing of medicines. https://www.securingindustry.com/pharmaceuticals/us-bill-sets-10-year-deadline-for-pack-level-tracing-of-medicines/s40/a1845/#.V4MhEo4i7S9. Accessed March 8, 2017.
5. 503B Outsourcing Facilities - U.S. Food and Drug Administration. (2015, October 6). http://www.fda.gov/Drugs/GuidanceComplianceRegulatoryInformation/PharmacyCompounding/ucm393571.htm. Accessed March 8, 2017.
6. Brochure WF, Maren TH. pH and drug ionization affects ocular pressure lowering of topical carbonic anhydrase inhibitors. Invest Ophthalmol Vis Sci. 1993;34:2581-2587.
7. Zore M, Harris A, Tobe LA, et al. Generic medications in ophthalmology. Br J Ophthalmol. 2013;97(3):253-257.
8. Baklayan GA, Patterson HM, Song CK, Gow JA, McNamara TR. 24-hour evaluation of the ocular distribution of (14)C-labeled bromfenac following topical instillation into the eyes of New Zealand White rabbits. J Ocul Pharmacol Ther. 2008;24(4):392-398.
Stephen Pruett, OD
• Optometrist at The Eye Centers of Racine & Kenosha in Wisconsin
• Financial interest: none acknowledged
Inder Paul Singh, MD
• Glaucoma specialist at The Eye Centers of Racine & Kenosha in Wisconsin
• Financial interest: none acknowledged