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ber, under the iris, at the conclusion of cataract sur- gery to prevent post-op inflammation. The FDA approval increases surgeon and patient confidence in the product, according to Dr. Matossian. She points out surgery initiates the inflammatory response and surgeons want to minimize the inflammatory cycle as soon as possible, which she says Dexycu can help accomplish. She says administering the medication in tissue near the iris and ciliary body before surgery prevents inflammation from the beginning and administering it behind the iris at the conclusion of surgery before sealing the incision helps minimize post-op inflammation. • Dextenza, a dexamethasone intracanalicular implant, can be inserted into the inferior punctum at the conclusion of surgery. The plug stays in place for up to 30 days, delivering a higher initial dose and tapering over time. "Both of these options take control back from the patient and give it to the surgeon, reduce the drops that need to be administered and deliver a steroid over 30 days with a tapering, which delivers more steroids immediately after surgery and less over the 30-day period," says Dr. Matossian. Dr. Devgan says they could prove particulary useful during certain challenging cases. For exam- ple, patients who present for surgery with uveitis are more prone to suffering post-op inflammation, points out Dr. Devgan. "In addition to prescribing topical steroids, adding Dexycu in the eye would provide for help in preventing the complication," he says. He acknowledges a risk of leaving medication in the eye after surgery. "It's not always known if a patient has steroid response glaucoma," he says. "A patient who's taking drops can stop administering them, but a surgeon would have to reenter the eye to remove the sphere." He also points out the sphere can shift after it's placed behind the iris, requiring, in some cases, a second surgery to remove it. Dextenza's intra- canalicular plug, on the other hand, can be removed if the surgeon notices a post-op increase in intraoc- ular pressure. • Omidria. This combination of ketorolac and phenylephrine is added to balanced salt solution and infused into the eye throughout surgery to help maintain pupil dilation and provide an anti-inflam- matory effect. Prostate medications such as Flomax affect the iris muscle and increase the risk of floppy iris syndrome, which occurs in 75% of men on those medications and in 25% of the general population. Miosis can occur in patients who are not on Flomax or who don't remember or realize they're taking a medication with similar properties, points out Dr. Matossian. "Establishing and maintaining a dilated pupil lets surgeons operate safely and effectively," she says. "Pupils constricting unexpectedly leads to a higher risk of complications." Omidria has also been shown to reduce pain dur- ing surgery and in the immediate post-op period, according to Dr. Matossian. At what cost? The commercially produced medications are expen- sive — adding between $450 and $700 per case — and therefore cost prohibitive without pass-through status, which allows facilities to bill CMS separately for the drug. With Omidria's pass-through status expiring on Oct. 1, CMS no longer provides a sepa- rate reimbursement for the drug. Omeros, the maker of Omidria, is pursuing sepa- rate payment coverage under "no opioid" legisla- tion, which applies to non-opioid pain management surgical drugs that are used in the surgery center setting and considered a surgical supply under CMS' Outpatient Prospective Payment System. Omeros says Omidria meets those criteria and qual- ifies for separate payment for the rest of 2020 and 2021. There was no update available on Omidria's payment status at the time of print. The pass- through statuses of Dexycu and Dextenza remain in place through 2021. The price of medications used during cataract pro- cedures is a significant factor as CMS pays surgeons about $500 per case and reimburses facilities about twice that amount. "There are low-cost options in intracameral medications with long tracks records of success and are accepted as the norm in cataract surgery," says Dr. Devgan. "Still, I welcome innova- tion and like having more tools in my toolbox." OSM N O V E M B E R 2 0 2 0 • O U T P A T I E N T S U R G E R Y . N E T • 6 3