EyeWorld Asia-Pacific March 2021 Issue

FEATURE EWAP MAR C H 2021 13 the literature conflicts as to whether one is necessary. A large, retrospective study by Modjtahedi et al. found that topical NSAIDs were associated with only a modest decrease in postoperative macular edema. 1 “The risk for PME is low and the number of patients benefiting from treatment is small,” Modjtahedi et al. wrote. In contrast, the literature review by Hoffman et al. describes NSAIDs as “an important adjunctive tool for surgeons performing routine and complicated cataract surgery.” 2 Dr. Savetsky said there are reasons other than CME prevention to use NSAIDs. “If it prevents CME in more patients than not, it’s a nice additive,” Dr. Savetsky said. “I like the NSAID because I think they are particularly good at pain control versus corticosteroids. When you prescribe an NSAID and steroid, you then have a synergistic effect, where you hit two different areas of the inflammatory pathway. “Prevention of miosis is another benefit, but mostly I think of pain and the synergy with a steroid,” he continued. “My objective is to get rid of the inflammation quickly, so the better I can do that, the better the comfort of the patients, and potentially a better outcome.” Dr. Saidel also noted the benefit of NSAIDs for pain. “For me, that’s where NSAIDs shine in maintaining patient comfort,” he said. Up until 10 years ago, Keith Walter, MD, was only using an NSAID without a steroid. Pooja Khamar, MS, PhD Narayana Nethralaya India ASIA-PACIFIC PERSPECTIVES T he authors have done a brilliant job. The postoperative regimen is unique and also takes care of the compliance-related issues related to the postoperative topical medications. Postoperative protocols and regimens post-cataract surgery have evolved over decades just in line with the technology used for the surgery. However, we believe that the combination of a steroid, antibiotic agent, and an NSAID works best as per our experience. We use intracameral moxifloxacin at the end of the procedure, followed by the use of preservative-free topical antibiotic agents such as moxifloxacin/gatifloxacin four times a day for 1 week, topical steroids such as prednisolone acetate 1% in tapering dose and nepafenac three times a day for 6 weeks. The addition of topical or oral moxifloxacin to the intracameral dose can extend the duration of bactericidal coverage. 1 We do not advocate use of intracameral or intravitreal steroid agents as the clinical evidence supporting their indication post cataract surgery is not robust. Also, we believe the risk of steroid response outweighs the perks of keeping the patient off steroids post-surgery. Patients today are very well sensitized to the use of postoperative medications and the need for compliance. Counseling the patient does help in improving the compliance to medications. Compounded drops do work well for old patients without a care-taker or dexterity issues. Increasing antibiotic resistance should be kept in mind while continuing the compounded drops for 4–6 weeks; the multi-drug regimen gives the physician the liberty of stopping the antibiotic after 1 week unless deemed necessary. The duration of action of intracameral/intravitreal steroid is around 21 days; we believe postoperatively the inflammation has to be kept in check and there is enough evidence to support the role of topical agents for 4–6 weeks post-surgery in keeping the postoperative inflammation in check. Compounded drops particularly consisting of a steroid and antibiotic combination can be used, but as mentioned antibiotic resistance has to be kept in mind. A postoperative regimen has to be based on evidence and the clinical experience of the physician over time. Use of intravitreal or intracameral steroids does help in overcoming the compliance-related issues related to the postoperative topical medications; however, in view of the added side effects of steroid response and endophthalmitis, we feel that the standard regimen being equally effective is safer, if only we could tackle the compliance-related issues with more robust postoperative counselling. Reference 1. Lukewich MK, et al. Incremental effect of topical and oral moxifloxacin administration with surgical intracameral prophylaxis. Can J Ophthalmol. 2021 Jan 27:S0008-4182(21)00005–3. Editors’ note: Dr. Pooja Khamar declared no relevant financial interests.