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Cover Focus | Jul/Aug '14

Generic Versus Branded Drops

A face-off of cost, compliance, and convenience

All of us would agree that explaining and managing postoperative drops after cataract surgery has lately become a cumbersome chore. We once could offer our patients the best antibiotic coverage and the greatest chance of reducing macula edema with the appropriate medications. However, after recent changes in insurance coverage, many of my patients have been forced to opt for generic drops, which are less effective and more complicated to dose than branded options. It was hard enough for my staff and I to offer directions and go over our colored handouts on how to use one antibiotic, one steroid, and one nonsteroidal drop over the usual 4-week time period. Now, patients are literally coming back with dozens of different choices of medications that the pharmacies have taken the liberty of changing without informing our office.

Some surgeons have reported a skyrocketing of generic drug prices in their communities. It has been hypothesized that these increasing costs are the result of greater demand for generic drops due to mandatory generic substitution laws, managed care tiered pricing, pharmacy policies to switch to generics, and more widespread insurance coverage.1 At play may also be a decreased supply of generic options, resulting from drug shortages and fewer generic companies due to consolidation in the pharma industry.

Verifying and explaining the change in the drops names and choices has become laborious and is a huge time-waster in my office. We now must have two staff members spend half their day managing callbacks and documenting changes in medications so that we can be sure we know exactly which drops our patients are using. It has been disappointing to have to refer more of my premium IOL patients out to retina than before due to a greater incidence of macula edema, as I can no longer control the quality of medications my patients are being prescribed.


Fortunately, many other great surgeons have been wrestling with the same challenges described above. Therefore, they sought a quick, inexpensive fix that could bring the control of eye drop prescribing back to physicians. So sparked the birth of an innovative company called Imprimis and the option to offer our patients a new treatment option: dropless cataract surgery.

Since 2010, Jeffrey T. Liegner, MD, of Eye Care Northwest in Sparta, New Jersey, has safely performed more than 4,000 cataract surgeries using this new technique, which involves injecting a single intravitreal injection of a steroid-antibiotic combination to replace the traditional patient-administered eye drops. According to Dr. Liegner, the advantages of this method come down to “the three Cs”: cost, compliance, and convenience.

Imprimis made its initial move to commercialize the triamcinolone acetonide + moxifloxacin + vancomycin combination by acquiring Pharmacy Creations in February 2014. Mark Baum, CEO of Imprimis, is said to have three to five high-quality manufacturing sites around the country to produce and distribute drugs that are brought to us by doctors and other innovators. The proprietary, patent-pending technologies allow drugs such as triamcinolone and moxifloxacin (with or without vancomycin), which do not typically distribute evenly in a suspension, to be combined into a single medication. The formulations, TriMoxi and TriMoxiVanc, can be injected into the vitreous at the time of cataract surgery.

As Dr. Liegner reports, the contents of the vial are put into the sterile field directly into a tuberculin syringe drawn up by the surgical technician, which is placed on a 27-gauge Knolle hydrodissection cannula (Katena). Dr. Liegner then injects approximately 0.2 mL, leaving some additional TriMoxiVanc available for a sub-Tenon supplement in rare circumstances.

During viscoelastic placement prior to IOL implantation, in addition to inflating the capsular bag, Dr. Liegner adds some extra viscoeleastic under the iris inferionasally, where he plans to do his intravitreal injection. After inserting the IOL, he enters the Knolle cannula through the primary corneal incision and passes it along the surface of the capsule, with visible tenting until reaching the equator, upon which the capsular tenting ends, indicating arrival at the zonules. A slight posterior rotation of the cannula tip and depressive movement posteriorly—without any visible capsule movement—confirms proper placement.

According to Dr. Liegner, the greatest challenge in learning this technique is a blind pass behind the iris, which comes with watching and interpreting the appearance of the anterior capsule as the cannula slips radially outward and over it toward the zonules. The cannula easily passes into the zonules, and the injection should proceed slowly, filling the posterior space with added volume. About 75% of the time, the plume of drug into the vitreous is observed.


It is exciting to see one surgeon’s great idea of dropless cataract surgery gain so much interest and traction in such a short period of time and develop into Imprimis, a publically owned company. Over the past 8 months, there has been tremendous buzz about this compounded medication and its potential to change the way we treat our patients. Advances like dropless cataract surgery demonstrate how one bright mind can quickly find a solution to make our lives easier and strengthen the relationship between doctor and patients, regardless of the political and regulatory environment in which we operate.

1. Buznego C. Branded vs. generic options: what’s happening with drop prices? How does it impact the premium practice/procedure? Paper presented at: the AECOS Summer Symposium; July 24 to 27, 2014; Deer Valley, Utah.

Damien F. Goldberg, MD

Damien F. Goldberg, MD is in private practice at Wolstan & Goldberg Eye Associates in Torrance, California. Dr.Goldberg may be reached at goldbed@hotmail.com.


Going Dropless: Why I Opted Out of the Retail Pharmacy Games

By Ahad Mahootchi, MD

In August 2013, three of my Medicare patients scheduled cataract surgery and informed me that they were “price sensitive.” Accordingly, I wrote them each prescriptions for a generic nonsteroidal, a generic steroid, and a generic antibiotic.

Subsequently, those three patients cancelled surgery because, despite shopping around, they could not get the drops for less than $350. I had previously switched to some specific generics because the brand-name drops were that expensive. Additionally, the pharmacies refused to honor manufacturers’ discount cards. My staff was consumed with the unproductive work of retail pharmacy games.

Retail pharmacies love when a drug is high tier or noncovered. They simply make up a ridiculously high price, and patients pay it because they think it’s important to their doctors. Now we have 500% inflation of old generic drops. The pharmacies are making more money on the drops than some practices are on the surgery! Putting $200 or $350 between the patient and surgery will drive down volume. I was fed up.

I researched intracameral medicines and was stunned by the cost difference. With literature supporting superiority of intracameral antibiotics, safety data of the dose of steroid used by Imprimis Pharmaceuticals, and a long history of problem-free use of their compounded anti-inflammatory and antibiotic formulation (triamcinolone acetonide, moxifloxacin hydrochloride, and vancomycin), I was ready to save my patients money. The total cost to the system, in my experience, is $200 to $300 better than what we were doing with drops.

I now use Imprimis’ dropless compounded formulations for almost all cataract, glaucoma, and vitrectomy procedures. If these were used for most of the nearly 3 million annual cataract procedures nationwide, the cost savings could be between a $0.5 billion and $1 billion.

The formulations provide both a medical benefit and an economic benefit. Additionally, staff expenses to write prescriptions and refills, explain drug regimens, and answer pharmacy and patient calls are drastically reduced. In my experience, going dropless is a win-win-win for patients, ophthalmologists, and payers.

Ahad Mahootchi, MD, practices at The Eye Clinic of Florida, serving the Tampa area. Dr. Mahootchi may be reached at tel: (813)779-3338; or email: am@seebetterflorida.com.