10/1/18. Trending Now in Cataract Surgery. The Evolution of Cataract Surgery. To Participate in Live Audience Response:

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1 Trending Now in Cataract Surgery Mitch Ibach OD, FAAO Vance Thompson Disclosures: Glaukos (honoraria), Alcon (honoraria), Equinox (Investor) To Participate in Live Audience Response: Trending Now in Cataract Surgery Download Poll Everywhere App from your mobile app store Log on & choose I m Participating Join PollEv.com/destin Or to participate via mobile device without the app, text Destin to to join Cataract Surgery Evolution Time-line First cataract extraction; Dr. Daviel The first lens implant; Dr. Ridley The first foldable silicone IOL was used; Dr. Mazzocco Phacoemulsification first performed; Dr. Kelman First Femtosecond laser assisted cataract surgery; Dr. Nagy The Evolution of Cataract Surgery Retro-bulbar 12 mm incision Can opener capsulotomy Extracapsular PMMA lens Multiple sutures Subconj. injection/drops Shield Topical 1.8 mm incision Capsulorrhexis Phacoemulsification Foldable lens Sutureless Drops only No Shield 2015 Topical <1.0 mm (Laser) Capsulorrhexis (Laser) Laseremulsification Rollable/Adjustable lens Sutureless Drug Delivery No Shield Laser LRI 1

2 Growing Population for Cataract Surgery Average Age of US Cataract Patient is Declining In 2011, almost 800,000 surgeries will be performed on patients years old West ES, Behrens A, McDonnell PJ, et al. The incidence of endophthalmitis after cataract surgery among the U.S. Medicare population increased between 1994 and Ophthalmology 2005; New surgical approaches available to improve UCVA for many patients Established LASIK market validates that patients will pay for surgically improved vision #TrendingNow #TrendingNow Refractive Outcomes (ReLACS) A. Pre- and intraoperative tools B. ReLACs- Laser CEX Easing Pain Points A. IV Free CEX B. Less Drops/Dropless CEX Refractive Outcomes (ReLACS) A. Pre- and intraoperative tools A. Biometry- Lenstar and IOL master B. Topography C. Lens technology C. Special Calcs D. Intraoperative Aberrometry #Lenstar #Nidek OPD Scan Avg. corneal power Uncorrected Vision after Cat Sx Refraction at different OZs Steep Axis and Pupil size Angle Kappa > Avoid Multifocal Vision with astigmatism corrected (glasses, AK, Toric IOL) Corneal HOAs >0.4 to 0.5 means poorer image quality after Cat Sx 2

3 #SpecialCalcs= WHY? Assumption#1: 3 mm #SpecialCalcs= WHY? Assumption#2: D = (N air-n cornea) / r Single plane, n= Observation of many pts Fudged n for single plane Constant front/back ratio (Changed in refractive surgery) D = N air- N lefns / r front R post RSx D = Nlens- N air / r back Reeves- IOL after refractive surgery Reeves- IOL after refractive surgery #Intraoperative Aberrometry (ORA) ORA System Optiwave Refractive Analysis Aphakic Refraction Toric Implants Surgically Induced Astigmatism Posterior K Astigmatism #Intraoperative Aberrometry (ORA) ORA System - Routine Cases % of Patients within.50d Aphakic Refraction 60% 84% 86% Lite rature** ORA w Veri feye ATIOLs N=1329 N=683 N=3380 **Anders Behndig, M.D., Ph.D., et al, Swedish National Cataract Registry. J Cataract Refract Surg. (July) 2012 #Intraoperative Aberrometry (ORA) ORA System - Post-Refractive Aphakic Refraction Mean Absolute Error ORA Screenshots Toric Implants Aberrometr y Surgeon Best Choice Ha igis L Shammas 1. Ianchulev T, Hoffer KJ, Yoo SH, et al. Intraoperative refractive biometry for predicting intraocular lens power calculation after prior myopic refractive surgery. Ophthalmology 2014;121:

4 Before Rotation ORA w/toric IOLs Toric Implants After Rotation Surgically Induced Astigmatism St. Dev.? x 92 Va sc 20/70 Plano Va sc 20/20 Why to Trust Aberrometry with Posterior Astigmatism Posterior K Astigmatism Its better to measure than estimate Measurement of Astigmatism: Comparability of Three Devices Used in the Preoperative Evaluation for Cataract Surgery. ~20% of patients don t have ATR on the posterior cornea Taylor Slingsby, MSIV 1, Mitch Ibach, OD 2, John Berdahl, MD 2 1 University of South Dakota Sanford School of Medicine, Vermillion, SD 2 Vance Thompson Vision, Sioux Falls, SD 1. Koch DD, Ali SF, Weikert MP, et al. Contribution of posterior corneal astigmatism to total corneal astigmatism. J Cataract Refract Surg 2012;38: The authors have no financial interest in the subject matter of this presentation. Device vs Subjective Refraction (SR): Astigmatism magnitude - Lenstar showed the greatest correlation and agreement with SR Table 1 Difference in Astigmatism Magnitude: Device Vs Post-Op Subjective Refraction Pearson Correlation Device P Value a Mean Difference (D) ± SD IQR 95% LoA r Value P Value Cassini ± 0.664* [ to ] -1.8, < Lenstar ± 0.556* [ to 0.193] -1.2, < Nidek ± 0.731* [ to ] -1.7, < D = diopters; SD = standard deviation; IQR = Interquartile range; LoA = limits of agreement a P values indicate the statistical significance of the difference with post-operative subjective refraction. P values calculated with the paired-samples t test. Difference calculated as (subjective refraction cylinder device astigmatism) * indicates statistically significant difference (p<0.05) N = 43 Results: 4

5 When to Trust Aberrometry ORA Posterior K Astigmatism 25.0% More than 0.5D of Residual Astigmatism 23.4% 20.0% 15.0% 10.0% 10.8% 5. 0% 0. 0% Wi th O RA Co nvet i onal App r oach Data on File Alcon #TrendingNow Femtosecond Precise Capsulotomy Refractive Outcomes (ReLACS) A. Pre- and intraoperative tools Refractive Laser Assisted Cataract Surgery B. ReLACs- Laser CEX A. Precise Capsulorhexis B. Less Phaco energy C. Effective Lens Position (ELP) C. Lens technology Perfect centration Precision diameter: < ± 0.25 mm No radial tears Easy and complete removal of capsule No adverse events Nagy Z, Takacs A, Filkorn T, Sarayba M. Initial clinical evaluation of an intraocular femtosecond laser in cataract surgery. J Refract Surg. 2009;25(12): Capsulotomy Diameter Accuracy (Absolute difference between Attempted and Acheived) Laser (n=60) Manual (n=60) Percent of Sample (%) <=0.2 5 <=0.5 <=0.7 5 <=1.0 <=1.2 5 <=1.5 Diameter Error (mm) 100% of LenSx Laser procedures achieved an accuracy of 0.25 mm Only 10% of manual procedures achieved an accuracy of 0.25 mm No radial tears Nagy Z, Takacs A, Filkorn T, Sarayba M. Initial clinical evaluation of an intraocular femtosecond laser in cataract surgery. J Refract Surg. 2009;25(12): Chang, D. (2016, May). Perfecting CAPSULOTOMY. Ophthalmology Times, 41(8), 1. 5

6 Zepto Capsulotomy Photodisruption or Fragmentation 1. Femtosecond laser energy is absorbed = plasma formation 2. Plasma leads to excited and ionized molecules. 3. Ionized molecules lead to cavitation bubbles. 4. C-bubbles expand separation tissue 5. Converting Laser energy to mechanical energy = Photodisruption Donaldson, K., Braga-Mele, R., Cabot, F., Davidson, R., Dhaliwal, D., & Hamilton, R. (2013, November). Femtosecond laser assisted cataract surgery. Journal of Cataract and Refractive Surgery, 39, The reduction in ultrasound/phaco energy used during Laser Refractive Cataract Surgery may result in less inflammatory response and preservation of endothelial cells CCT was significantly lower (p<.05) compared to the control group at 1 day PO Effective Lens Position with Premium Lens Three Month Variability in Effective Lens Position (ELPo) Standard Deviation (mm) LenSx (n=31) Manual (n=30) p=< 0.05 *Using Warren Hill ELPo Calculator 34 Start to finish ReLACS Video #TrendingNow Refractive Outcomes (ReLACS) A. Pre- and intraoperative tools B. ReLACs- Laser CEX LSX13204SK 35 C. Lens technology A. AK s/lri s w/wo Femto B. Toric IOLs C. MFIOLs D. Calhoun LAL E. Symphony 6

7 Goals Minimize other pathology Patient goal/desire Psychology of ReLACs #TrendingNow Astigmatic Keratotomy vs. Limbal Relaxing Incision Refractive Outcomes (ReLACS) A. Pre- and intraoperative tools B. ReLACs- Laser CEX CRI s C. Lens technology A. AK s/lri s w/wo Femto Up to 95% of eyes have some measurable astigmatism. Toric IOL AK central = bigger effect 1:1 LRI Peripheral = less effect Hyperopic Shift Femtosecond Laser AK s Femtosecond Laser AK s Manual AKs/LRIs - Correct 2D Astigmatism - Based on Pre or Intra or Post op Measurement - Variability in Depth and Arc Length - Higher risk of perforation Femto AKs - Correct 2D Astigmatism - Based on Pre or Intra Measurement - Precise Depth, Axis and Arc Length - Intrastromal Option (Then open>> effect) - nomogram 7

8 Toric IOLs Toric IOL Misalignment Misalignment % Loss T3 (1.03D) Absolute Loss T9 (4.11D) 0deg 0% 0D 0D 5deg 17.5% 0.18D 0.71D 10deg 35% 0.36D 1.43D 15deg 50% 0.51D deg 100% 1.03D 4.11D Toric Misalignment of T9 Causes of Residual Astigmatism Wrong Location Poor Measurements Poor Calculations Surprising SIA Posterior Ks IOL Rotated Poor IOL Placement Wrong Lens Poor Measurements Poor Calculations Surprising SIA Posterior Ks Wrong Eye Ocular Surface Disease ABMD Irregular Astigmatism Treat Disease Step heights decrease peripherally Multifocal Implants Anterior aspheric wavefront= Less spherical aberration Tecnis Multifocal Advantage: Focus light rays and distance, near, and intermediate simultaneously Diffraction: bending of light around corners, MFIOL uses concentric circles to bend to multiple foci. Disadvantage: Night time glare and halos (simultaneous vision) Advances in optics to minimize night time vision problems Posterior diffractive surface Whitsett, J., & Chang, D. (2015). TECNIS MULTIFOCAL FAMILY OF 1-PIECE IOLs. In Abbott- Tecnis Family of IOLs. Retrieved August 29,

9 Spectacle Independence at 3 distances 20/25 20/32 20/32 20/25 20/32 88% 86% 20/20 20/25 20/20 84% 82% 80% 78% 87% 85% 20/20 76% 74% 77% 72% Kim, J. S., Jung, J. W., Lee, J. M., Seo, K. Y., Kim, E. K., & Kim, T. I. (2015, July). Clinical Outcomes Following Implantation of Diffractive Multifocal Intraocular Lenses With Varying Add Powers. American Journal of Ophthalmology, 160(4), Kim, J. S., Jung, J. W., Lee, J. M., Seo, K. Y., Kim, E. K., & Kim, T. I. (2015, July). Clinical Outcomes Following Implantation of Diffractive Multifocal Intraocular Lenses With Varying Add Powers. American Journal of Ophthalmology, 160(4), LONG-TERM SUSTAINABILITY High patient satisfaction PERCENT OF PATIENTS WHO WOULD ELECT TO HAVE THE SAME IOL AGAIN 1 ENHANCED FUNCTIONALITY More than 90% of TECNIS Multifocal D patients report no difficulty with night vision. 1,2 DEGREE OF DIFFICULTY 2 WITH NIGHT VISION (With glasses if you need them) DEGREE OF DIFFICULTY 2 WITH GLARE/FLARE (With glasses if you need them) DEGREE OF DIFFICULTY 2 WITH HALOS (With glasses if you need them) 1. TECNIS Multifocal 1-Piece IOL DFU. Abbott Medical Optics Inc., Santa Ana, TECNIS Calif. The questionnaire was not determined to be a psychometrically valid MULTIFOCAL IOLs PP2015CT0547 assessment of the concept of spectacle independence. 51 TECNIS Multifocal IOLs have a full diffractive posterior surface makes the optic pupil-independent, which is especially im portant for low-light conditions. WARNINGS: Contrast sensitivity is reduced with a multifocal lens compared to a monofocal lens. Therefore, patients with multifocal lenses should exercise caution when driving at night or in poor visibility conditions. See Important Safety Information continued on page TECNIS MULTIFOCAL IOLs PP2015CT TECNIS Multifocal 1-Piece IOL DFU. Abbott Medical Optics Inc., Santa Ana, Calif. 2. On scale of 1 7. TECNIS Multifocal 1-Piece Low Add DFU. Abbott Medical Optics Inc., Santa Ana, Calif. 52 AcrySof IQ ReSTOR Chiam, P., Chan, J., Aggarwal, R., & Kasaby, S. (2006, September). ReSTOR Intraocular Lens implantation in Cataract Surgery: Quality of Vision. Journal of Cataract and Refractive Surgery, 32,

10 #Nidek OPD Scan Avg. corneal power Uncorrected Vision after Cat Sx Refraction at different OZs Two New/Coming IOL Options Steep Axis and Pupil size Angle Kappa >0.4 Avoid Caution w/multifocal Vision with astigmatism corrected (glasses, AK, Toric IOL) Corneal HOAs >0.4 means poorer image quality. Caution with MFIOL AMO Symphony EDOF AMO Symphony EDOF 96% of patients were UCVA 20/25 or > at intermediate 92% of patients were UCVA 20/40 or > at near RxSight LAL-What s Special? Symfony EDOF regular silicone polymers + mobile, silicone subunits, called macromers photosensitive 10

11 Adding Power to the LAL The LAL FDA Clinical Trials Iris light light lock-in Accuracy Increased power => change in radii of curvature => change in power No patient seeing less than 20/20 uncorrected Choose the Right Foot.and attached patient Polish It Choose the right shoe Put it on correctly Relax with ReLACS How many of you have worked with Premium IOLs? Experiences? 11

12 What IOL would you choose for you own CEX? 1. Monofocal with glasses 2. Distance correction, AK s or Toric 3. MFIOL 4. Calhoun LAL 5. Symfony EDOF IOL If you ask me anything I don t know.....i m not going to answer -Yogi Berra #TrendingNow Challenges/Pain Points in Cataract Surgery Refractive Outcomes (ReLACS) A. Pre- and intraoperative tools B. ReLACs- Laser CEX C. Lens technology Easing Pain Points A. IV Free CEX B. Less Drops/Dropless CEX Patients Drops IVs Outcomes Recovery time Others Surgeons & Staff Paperwork Drops IVs Costs Turnover Outcomes

13 IV Free Conscious Sedation Compounded Formulation* Genesis of the Meltaway Started using Sublingual Versed 3 years ago Liquid under tongue Fast On/Off Sliding Dosing Scale Patients didn t Startle Patients Loved not getting Ivs Staff Loved not starting Ivs MKO Melt 3mg of Midazolam 25mg of Ketamine HCl 2mg Ondansetron Compounded Lemon Flavor Sublingual Melt for Administration Single-use prescription Heard Surgeons like IV Ketamine Analgesic-- Pain suppressor Ketamine Stare-- mesmerized Mild euphoria -- care-free Safe *Compounded by a pharmacist pursuant to an individual patient. May be customized. Administration 1-2 MKO Melts administered under the tongue Dosing determination made by anesthetist/anesthesiologist Based primarily on age, secondarily on weight, and alcohol/ benzodiazepine use of patient Takes approximately 2-5 minutes to dissolve Patients have reported feeling effects within 1-2 minutes Lemon flavored slightly bitter We currently use in 99% of cataract surgeries in our practice Bill Wiley, MD Practice Evaluation* MKO Experience Total Surveyed* Preferred MKO Melt % of Total Preferred IV % of Total % 6 25% *12 performed by Dr. Wiley and 12 performed by Dr. Bafna Patients surveyed had cataract surgery in one eye with IV anesthetic and the second eye using the sublingual MKO troche for conscious sedation Preferred MKO Melt 17 Patients surveyed said troche was equal to having of IV 12 Patients surveyed preferred troche because it is non-invasive; and/or do not like IV 1 Patient surveyed preferred troche because they did not feel as tired post surgery Preferred IV 4 Patients surveyed preferred IV because they felt less pain; less aware of IV (each patient had 1 troche at 2nd visit 2 Patients surveyed preferred IV because they indicated they were too tired post operatively 1 Patient surveyed preferred IV because taste of troche was not pleasant Refractive Outcomes (ReLACS) A. Pre- and intraoperative tools #TrendingNow Easing Pain Points A. IV Free CEX Loving Touching Squeezing B. ReLACs- Laser CEX C. Lens technology B. Less Drops/Dropless CEX A. Ocular Therapeutix B. Intravitreal injections

14 Ocular Therapeutix- Steroid Punctal Plug Trial Ocular Therapeutix- Steroid Punctal Plug Trial Purpose: To evaluate pain and inflammation after cataract surgery in patients who received a dexamethasone punctal plug in place of topical steroids. Methods: 1) multi-centered, randomized (Placebo vs. punctal plug), double masked, phase 3 FDA clinical trial. 2) Dissolvable plug with 0.4mg of dexamethasone. 3) 240 patients, 6 follow-up visits. 4) **At any point in the study patients may be prescribed Rescue anti-inflammatory medications, mainly steroids Ocular Therapeutix- Steroid Punctal Plug Trial 70 % 60 % 50 % 40 % 30 % 20 % 10 % 0% Results: from Ocular Therapeutix Stage 2 FDA trial 1) Absence or no anterior chamber cell at day 14:à 34.5% in the plug group vs. 3.4% in the placebo group 2) Absence or no anterior chamber cell at day 30:à 62.1% in the plug group vs. 13.8% for placebo 35% Plug Group Placebo Group 3% 62% Day 14 Day 30 14% Ocular Therapeutix- Steroid Punctal Plug Trial 10 0% 90 % 80 % 70 % 60 % 50 % 40 % 30 % 20 % 10 % 0% Results: from Ocular Therapeutix Stage 2 FDA trial 1) Dexamathasone plug retention day 30 : 97% 2) Percent of patients needing rescue steroid at day 14: 20% in the plug group vs. 72% in the placebo group. 97% Retenention of plug 20% Rescue Meds Plug Group Ocular Therapeutix- Steroid Punctal Plug Trial Evaluating the patient experience after implantation of a 0.4 mg sustained release dexamethasone intracanalicular insert (Dextenza TM ): results of a qualitative survey Dextenza Punctal Plug Comfortable Very or extremely comfortable 100% 96% More convenient than drops 96% Some pain, inflammation, or vision changes after CEX 44% If had a 2 nd CEX, patient would chose steroid plug 88% Jira,., Sampson,., Silverstein,., Walters,., Metzinger,., & Talamo,. (2017, March 8). Evaluating the patient experience after implantation of a 0.4 mg sustained release dexamethasone intracanalicular insert (DextenzaTM): results of a qualitative survey. Patient Preference and Adherence- Dove Press,

15 Introducing TriMoxi/Dex-Moxi-Ketor and Drop a Day Cataract Surgery (DAD) WHAT? à Drop a Day DAD - is an injection of an antibiotic & steroid combination in the eye at the time of surgery. More than 90% of patients are nonadherent to their ocular medication dosing regimens, and nearly 50% discontinue taking their medications before 6 months 1 Nordstrom BL. Persistence and adherence with topical glaucoma therapy. Am J Ophthalmol. 2005;140: Preparation: 1. triamcinolone 2. moxifloxacin One intravitreal injection WHAT? Where? Pars plana injection into the vitreous cavity or now into anterior chamber. Sub-conj Depot Medicine is injected after the IOL placement. Patients are still under anesthesia so it is mostly painless What? The doctor can expect View of the injected medication 2 hours after injection Benefits of DAD- #3C s Compliance Convenience Cost 15

16 Endophthalmitis Rates Archives of Ophthalmology: the rate of Endophthalmitis was 0.128%. This same review showed a large increase in cases from , rate of 0.265%. Friedman, Neil, Peter Kaiser, and Roberto Pineda, II. Massachusetts Eye and Ear Infirmary Illustrated Manual for Ophthalmology. 3rdrd ed. New York: Elsevier (Saunders), Digital. Rates of Endophthalmitis 0.25% 0.20% 0.15% 0.10% 0.05% Safety? 0.00% A-no anti biotic 0.23% B-intracameral cefuroxime 0.05% C-topical levofloxacin 0.17% D-intraca meral & topical 0.03% Braga-Mele, R., Chang, D., Henderson, B., Mamalis, N., Talley-Rostov, A., & Vasavada, A. (2014, December). Intracameral antibiotics: Safety, efficacy, and preparation. Journal of Cataract & Refractive Surgery, 40, Take Home Point 1). This study showed a 5-fold decrease in endophthalmitis with intracameral cefuroxime Why? Kaiser Study Endophthalmitis cases per 1000 Percent of patients receiving injecti ons of post-op meds Convenience Topical Only Some injections Topical and Injection 22 (2100%) fold decrease in endophthalmitis from Shorstein, N., Winthrop, K., & Herrinton, L. (2013, January). Decreased postoperative endophthalmitis rate after institution of intracameral antibiotics in a Northern California eye department. Journal of Cataract & Refractive Surgery, 39, Convenience 128 drops 30 drops Drops Vigamox - ShopKo Pred - Walgreens Ilevro - ShopKo Total = $457 Cost TriMoxi Tri-Moxi - $25 No cost to patient Ilevro - ShopKo Total = $ fewer drops = $ = $

17 Hurdles Moving Forward Hurdles and or Reservations 1) Off-Label 2) Compounding Pharmacy TASS 3) Steroid Responders. Promising Attributes 1) Better compliance 2) Less patient aggravation/time 3) Less corneal toxicity 4) Sting from drops eliminated 5) Better Safety- AAO preferred guidelines. Antibiotics above suprathreshold levels 6) Cost 1) Cost to patient ) Cost to insurance companies Concerns with DAD/TriMoxi-DexMoxiKetor 1. Cystoid Macular Edema 2. Steroid response/ IOP spikes 3. HORV 4. Overall experience Fisher, B. L., & Potvin, R. (2016). Transzonular Vitreous Injection vs. a Single Drop Compounded Topical Pharmaceutical Regimen After Cataract Surgery. Clinical Ophthalmology, 10, Concerns with DAD/TriMoxi 1. Cystoid Macular Edema 1. This study measured macular thickness in both arms at both 1 week and 1 month post-op 2. No statistically significant difference in macular thickness Why? Drop a Day vs. Dropless -AAO Systematic Review: Prevention of Inflammation and Macular Edemaà Steroids vs. Nonsteroidal Anti-inflammatory Eye Drops post CEX. - 7 randomized clinical trials were reviewed. 25.3% vs. 3.8% Steroids alone NSAIDs alone Rates of P.O. CME Fisher, B. L., & Potvin, R. (2016). Transzonular Vitreous Injection vs. a Single Drop Compounded Topical Pharmaceutical Regimen After Cataract Surgery. Clinical Ophthalmology, 10, Kessel, B., Tendal, B., Jorgensen, K., Erngaard, D., Flesner. P. (2014) "Post-Cataract Prevention of Inflammation and Macular Edema by Steroid and Nonsteroidal Antiinflammatory Eye Drops." American Academy of Ophthalmology121.10: Web. 22 Feb Cystoid Macular Edema Concerns with DAD/TriMoxi 2. Steroid response/ IOP spikes 1. Compared at Baseline, 1 day PO, 1 week PO, and 1 month PO 2. No statistically significant difference in IOP, no significant drift over time. Percentage of Eyes with IOP Spike (%) Figure 3. IOP Spikes of At Least 15 mmhg at Post-Operative Visits p = Concern of IOP Spikes? p = p = p = da y 1- w eek 1- m on th 3- m on th TriMo xivanc Drops Fisher, B. L., & Potvin, R. (2016). Transzonular Vitreous Injection vs. a Single Drop Compounded Topical Pharmaceutical Regimen After Cataract Surgery. Clinical Ophthalmology, 10, Figure 3. Percentage of eyes with an intraocular pressure spike of at least 15 mmhg from baseline IOP. Overall, the incidence of pressure spikes decreased over time in both the TriMoxiVanc (DAD) group and the traditional drops group. 17

18 1. Cystoid Macular Edema Concerns with DAD/TriMoxi Concerns with DAD/TriMoxi 1. Overall experience Patient Experience Drops vs. TM 100% 2. Steroid response/ IOP spikes 80% 60% 92% 88% 3. HORV 40% 20% 0% TM vs. Drops Overall Experience Vi sion Pos t-op. Fisher, B. L., & Potvin, R. (2016). Transzonular Vitreous Injection vs. a Single Drop Compounded Topical Pharmaceutical Regimen After Cataract Surgery. Clinical Ophthalmology, 10, Fisher, B. L., & Potvin, R. (2016). Transzonular Vitreous Injection vs. a Single Drop Compounded Topical Pharmaceutical Regimen After Cataract Surgery. Clinical Ophthalmology, 10, Conclusion? 1. What is the Standard of Care? ²According to ESCRS 75% ²2014 ASCRS Endophthalmitis survey: 47% current or 6 months 2. AAO 2011, 1.82 million CEX in Medicare population 1. Cost to Medicare in post-op ABX ($75.00) alone was 136 million ²Thomas Kuhn s 1962 Text The Structure of Scientific Revolutions THANK YOU QUESTIONS? ²Rest Easy Cataract in the AdultEye PPP San Francisco, CA: American Academy of Ophthalmology. Accessed June 7, Chang, D. (2015, January). Results of 2014 ASCRS endophthalmitis antibiotic prophylaxis survey. Eyeworld, Barry, P. (2014, January). Adoption of intracameral antibiotic prophylaxis of endophthalmitis following cataract surgery.journal of Cataract & Refractive Surgery, 40,