EyeWorld Asia-Pacific December 2020 Issue

CATARACT 36 EWAP DECEMBER 2020 Lewis Levitz, MD Vision Eye Institute, Melbourne 27 Denmark Hill Road, Hawthorn East 3123, Victoria, Australia lewis.levitz@vei.com.au ASIA-PACIFIC PERSPECTIVES A recent paper reports that using bromfenac both pre- and post-surgery results in less cystoid macular edema (CME) compared to corticosteroid combined with a nonsteroidal anti-inflammatory drug (NSAID) used postoperatively only. 1 This prompted three surgeons in the U.S. to each give their opinion with regards to CME prevention. Dr. K. Walters preferred using bromfenac preoperatively and postoperatively without the use of a corticosteroid. Dr. W. Trattler suggested using both a NSAID and corticosteroid starting 3 days preoperatively. Dr. K. Miller suggested that prednisolone alone is enough for the majority of cases. The belief that NSAIDs act synergistically with corticosteroids in preventing pseudophakic CME is based upon the findings of two recent studies. The PREMED study reported that combined NSAID and corticosteroid decrease the incidence of CME greater than monotherapy with either agent. 2 However, this study just showed an additive effect of two anti-inflammatory agents (greater dosing) versus one. A systematic review by Kessel et al. reported that NSAIDs are more effective than corticosteroids in preventing CME. This review has been criticized as fluorometholone (a surface corticosteroid) was the most commonly used corticosteroid in the studies analyzed and the reported conclusions bore no relationship to the studies quoted. 3,4 Those who believe that steroids alone are sufficient reference a report by the American Academy of Ophthalmology which found that there was no evidence that NSAIDs improved long-term visual outcomes or were synergistic with corticosteroids. 5 NSAIDs give no therapeutic benefit that cannot be achieved by corticosteroids alone. The evidence that NSAIDs do not reduce macular thickening was demonstrated in a prospective trial by Tzelikis. 6 With such opposing views, what should clinicians do? In a prospective randomized double blind study by McCafferty et al., they found no benefit of adding an NSAID in decreasing CME in patients without risk factors. 7 NSAIDs were beneficial in patients with vein occlusion, epiretinal membranes, and diabetic retinopathy. There is evidence that prescribing NSAIDs prior to surgery may improve visual outcomes in the short term. 8 It is not yet certain if this is due to the NSAID allowing greater mydriasis and therefore shorter operative time or due to its pharmacological effect. So, in 2020, evidence-based medicine suggests that NSAIDs given prior to the operation decreases inflammation in the first few days (an effect that a corticosteroid would likely also provide); however, there is no evidence-based reason to continue NSAIDs postoperatively unless the patient has known risk factors. 9 References 1. Walter KA, et al. Incidence of cystoid macular edema following routine cataract surgery using NSAIDs alone or with corticosteroids. Arq Bras Oftalmol . 2020. 2. Wielders LHP, et al. European multicenter trial of the prevention of cystoid macular edema after cataract surgery in nondiabetics: ESCRS PREMED study report 1. J Cataract Refract Surg . 2018. 3. Kessel L, et al. Post-cataract prevention of inflammation and macular edema by steroid and nonsteroidal anti-inflammatory eye drops: A systematic review. Ophthalmology . 2014;121(10):1915–1924. 4. Grzybowski A. Re: Kessel et al.: Post-cataract prevention of inflammation and macular edema by steroid and nonsteroidal anti-inflammatory eye drops: a systematic review ( Ophthalmology 2014;121:1915–24). Ophthalmology . 2015. 5. Kim, SJ, et al. Topical Nonsteroidal Anti-inflammatory Drugs and Cataract Surgery: A Report by the American Academy of Ophthalmology. Ophthalmology . 2015;122:2159–2168. 6. Tzelikis PF, et al. Comparison of ketorolac 0.4% and nepafenac 0.1% for the prevention of cystoid macular oedema after phacoemulsification: prospective placebo-controlled randomised study. Br J Ophthalmol . 2015;99(5):654–658. 7. McCafferty S, et al. Pseudophakic cystoid macular edema prevention and risk factors; prospective study with adjunctive once daily topical nepafenac 0.3% versus placebo. BMC Ophthalmol . 2017. 8. Donnenfeld ED, et al. Preoperative ketorolac tromethamine 0.4% in phacoemulsification outcomes: Pharmacokinetic- response curve. J Cataract Refract Surg . 2006;32(9):1474–1482. 9. Levitz LM, et al. Topical non-steroidal anti-inflammatory drugs are not the mainstay of prophylaxis and treatment for pseudophakic cystoid macular oedema. Clin Exp Ophthalmol . 2019. Editors’ note: Dr. Levitz declared no conflicting interests. from postoperative macular edema,” he said. “If you treat everyone with a nonsteroidal, you will treat 100 people for the sake of one or two.” If Dr. Miller finds patients do have CME, he puts them on a regimen of an NSAID and prednisolone, both 4 times a day until the edema is gone. “We usually taper them off the nonsteroidal first because it’s irritating, then we’ll taper them off the steroid,” he said. Currently, deciding the best approach means weighing all of these considerations and deciding which best suits a given patient. The doctors here stressed that performing the cleanest surgery possible can get patients off to a promising start. EWAP References 1. Walter KA, et al. Incidence of cystoid macular edema following routine cataract surgery using NSAIDs alone or with corticosteroids. Arg Bras Oftalmol. 2020;83:55–61. 2. Wielders LPH, et al. European multicenter trial of the prevention of cystoid macular edema after cataract surgery in nondiabetics: ESCRS PREMED study report 1. J Cataract Refract Surg. 2018;44:429–439. 3. Wittpenn JR, et al. A randomized, masked comparison of topical ketorolac 0.4% plus steroid vs steroid alone in low-risk cataract surgery patients. Am J Ophthalmol. 2008;146:554–560. Editors’ note: Dr. Miller is Kolokotrones Chair in Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California, and declared no conflicting interests. Dr. Trattler is Director of Cornea, Center for Excellence in Eye Care, Miami, Florida, and has interests with Alcon, Bausch + Lomb, Kala, Johnson & Johnson, Novartis, Omeros, and Sun Pharma. Dr. Walter is Professor of Ophthalmology, Wake Forest University, Winston-Salem, North Carolina, and has interests with Omeros and Sun Pharma.