EyeWorld Asia-Pacific June 2016 Issue

59 EWAP PHARMACEUTICALS June 2016 New focus on NSAIDs for cataract surgery by Maxine Lipner EyeWorld Senior Contributing Writer Physicians discuss prophylactic use of NSAIDs in cataract patients D oes the use of topical NSAIDs make sense for cataract patients? Among the primary uses for many is to keep cystoid macular edema (CME), which sometimes plagues patients after cataract surgery, at bay. Determining how frequently CME occurs depends upon what parameters are considered, according to Neal Shorstein, MD , ophthalmologist and associate chief of quality, Kaiser Permanente, Walnut Creek, California. In a study 1 published in the December 2015 issue of Ophthalmology , which Dr. Shorstein led, investigators compared the effectiveness of three different prophylactic strategies in preventing CME after phacoemulsification. Based on this study, Dr. Shorstein estimates that the rate of CME runs between 1 and 3%. “It can go as high as 40% if you are calling it CME primarily based on OCT evidence of fluid,” Dr. Shorstein said. In the recent study, investigators used visually significant CME, as determined by OCT evidence of CME, as well as a visual acuity of 20/40 or worse. When it comes to prophylaxis, in Dr. Shorstein’s view, NSAIDs may have a role to play. “In our study of more than 16,000 eyes, we saw a 55% reduction in the incidence of visually significant CME when topical NSAIDs were added to topical prednisolone,” he said, adding that the results were statistically significant and were consistent with a number of other studies. The practice of the surgeons included in the study was to prescribe NSAIDs for application 4 times a day for 4 weeks after cataract surgery. While none of the surgeons included in this retrospective study were prescribing the NSAIDs preoperatively, Dr. Shorstein thinks this may have value. “Some studies have shown that there’s an additional benefit from preoperative administration,” he said. John Wittpenn, MD , partner, Ophthalmic Consultants of Long Island, who led an earlier NSAID cataract study, agrees that prophylaxis with these is helpful. In this study, 2 appearing in October 2008 in the American Journal of Ophthalmology , investigators compared use of topical ketorolac 0.4% in combination with steroid to steroid alone for staving off post-phacoemulsification complications. While at the time, Acular LS (ketorolac, Allergan, Dublin) was the nonsteroidal being used, few people today are using this because the brand formulation is not available, Dr. Wittpenn pointed out. “They’re using either bromfenac as Prolensa [Bausch + Lomb, Bridgewater, NJ] or nepafenac as Ilevro [Alcon, Fort Worth, Texas],” he said. While full-blown CME was the endpoint of his study, other studies have considered macular thickening as an indication of this, Dr. Wittpenn said, adding that with this kind of study the same statistical difference that was found for ketorolac has been seen for Nevanac (nepafenac, Alcon, Fort Worth, Texas). In his study, the prophylaxis included having the NSAID on board beginning 3 days preoperatively. This has the added advantage of maintaining pupillary dilation, as well as decreasing pain with surgery, Dr. Wittpenn pointed out. “We have patients use the NSAID postoperatively for 4 to 5 weeks.” William Trattler, MD , Center for Excellence in Eye Care, Miami, who also participated in this study, agreed that use of NSAIDs can be helpful for patients undergoing cataract surgery. Typically, he puts patients on newer generation NSAIDs, such as Ilevro and Prolensa, for a month postoperatively. But for some he may use NSAIDs longer. “There are some patients who are at higher risk for CME than others or who have more inflammation in general, so we may extend it to 6–8 weeks,” he said. However, one has to be careful with the generic NSAIDs, as there can be ocular surface issues. There can be a big difference between brand name NSAIDs and generics, he finds. “When my patients get switched at the pharmacy, they typically have more ocular irritation with the generic, especially if there is preexisting dry eye,” he said. “Patients will experience more ocular surface irritation and staining with generic NSAIDs versus the brand names, which results in blurred vision.” Dr. Trattler pointed out that a few corneal melts have been reported with the topical NSAIDs in the past few years. “They seem to be mostly occurring with the generics,” he said, adding that if a patient has a compromised ocular surface, surgeons have to OCT image of a patient who underwent uncomplicated cataract surgery and developed CME postoperatively. Source: William Trattler, MD continued on page 60