EyeWorld India March 2012 Issue

49 March 2012 EW RETINA Preventing and treating CME by Vanessa Caceres EyeWorld Contributing Editor Prophylaxis key in avoiding problems T hink of prophylaxis for cystoid macular edema (CME) like life insurance, said Keith A. Warren, MD, chair, ophthalmology department, School of Medicine, University of Kansas, Kansas City, Kan., USA. Hopefully you won’t need it, but it can give you some clinical peace of mind. Uday Devgan, MD, chief of ophthalmology, Olive View– University of California, Los Angeles Medical Center, Calif., USA, approaches CME with another analogy: “When CME occurs, it’s like a carpet that’s flooded,” he said. “You can repair the carpet, but it’s never quite the same.” That’s why it’s better to prevent CME after cataract surgery from occurring in the first place, he added. For these reasons, surgeons like Drs. Warren and Devgan take a full- on approach to prevent CME. In addition to complications and poor visual outcomes, another reason to prevent it is because patients have trouble understanding how or why CME occurs, Dr. Devgan said. Prophylaxis pointers NSAIDs are the mainstay in prophylaxis for Dr. Devgan. He uses them a few days before and a few days after cataract surgery. Although this is actually an off- label use, he noted that it is a very common practice. Dr. Warren uses both NSAIDs and steroids with tapering dosages to prevent CME. Surgeons like Dr. Devgan and Dr. Warren said that prophylaxis against CME is so common for them, it is hard to compare visual outcomes in eyes that have been treated prophylactically against eyes that have received no treatment, as just about all eyes they operate on receive the prophylaxis. However, David D. Verdier, MD, Verdier Eye Center, Grand Rapids, Mich., USA, has a contrary view. “I do not routinely use NSAIDs following uncomplicated phaco,” he said. “These drugs can incur significant expenses as well as induce corneal surface problems from toxicity and reduced sensation. … I do not know if prophylaxis in non-high-risk patients offers any advantage over prompt treatment of CME when it occurs in non-high-risk patients.” That said, Dr. Verdier will use NSAIDs if the patient is at a higher risk for CME, with risk factors including epiretinal membrane, diabetes mellitus, cataract surgery complicated by vitreous loss, or a history of post-op macular edema after cataract surgery in the contralateral eye. “In these settings, I routinely use an NSAID such as bromfenac [Bromday, Ista Pharmaceuticals, Irvine, Calif., USA], nepafenac [Nevanac, Alcon, Fort Worth, Texas, USA/Hünenberg, Switzerland], or ketorolac [Acular, Allergan, Irvine, Calif., USA]. I continue the NSAID until topical steroids have been discontinued,” he said. Patients typically use these medications for 1-3 months, he said. Dr. Verdier emphasized his preference for generic NSAID use. “Unless there is compelling evidence of an advantage of more expensive non-generics, I think generic NSAIDs might be considered, out of respect to our AT A GLANCE • Prophylactic treatment of CME before it occurs can help avoid long-term damage • Common treatments to help prevent CME include the use of NSAIDs and topical steroids • If acute CME occurs, NSAIDs, steroids, intravitreal injections, and other medication options are commonly used • Chronic CME can present treatment challenges and is more common in patients with certain risk factors, such as diabetic retinopathy and uveitis Before (left) and after (right) treatment of CME with an NSAID Source: Uday Devgan, MD An epiretinal membrane, which makes it highly likely that the patient will have CME after routine cataract surgery Source: Uday Devgan, MD continued on page 50