EyeWorld India March 2012 Issue

50 March 2012 EW RETINA patients’ financial health,” he said. He also believes that optimal dosing for NSAIDs, in his hands, differs from what manufacturers recommend. For example, he uses nepafenac twice a day instead of three times a day and ketorolac two times a day instead of four times a day. Treating acute CME When acute CME occurs postoperatively, Dr. Devgan checks to make sure that other anatomical defects, such as vitreous behind the lens, are not occurring. If he does not find anything, he uses topical NSAIDs for treatment and follows the patient with the use of ocular coherence tomography on a week-to-week basis. He usually finds some improvement within 1-2 weeks of the peak incidence, but treatment with medications will continue for several weeks. Dr. Devgan prescribes NSAIDs such as Bromday, Acular, and Nevanac, and sometimes genetic choices. He also uses a topical steroid such as prednisolone acetate 1% (Pred Forte, Allergan) or Durezol (difluprednate ophthalmic suspension 0.05%, Alcon) if NSAIDs do not seem to improve the eye. Dr. Verdier’s treatment course for acute CME is very similar, adding that he will follow the treatment course and then taper over 1-3 months. “If [the patient] is recalcitrant to this treatment, I readily refer to a retinal specialist,” he said. Another CME treatment option is Diamox (acetazolamide, Duramed, Cincinnati, Ohio, USA), Dr. Devgan said. “Diamox as a pill lowers pressure in the skull and lowers IOP, and it may help with macular edema,” Dr. Devgan said. Dr. Warren also treats CME with NSAIDs three times a day for 6 weeks and periocular steroids such as Durezol. He will administer a sub-Tenon’s injection of triamcinolone 4 mg and discontinue the topical steroid but continue the NSAID for another 6 weeks if necessary. “Generally at about 6 weeks, I see improvement,” he said. A push for effective topical treatment over injections is a crucial issue right now in CME, Dr. Warren said. “It’s easier to do, and everyone likes it better,” he said. Treating chronic CME Chronic CME, which can occur 3-6 months after surgery, can be challenging to treat if it’s caused by an anatomical defect that was not fixed, Dr. Devgan said. “The longer CME is there, the worse the prognosis is,” he said. “It’s hard for the patient to understand what is happening.” Certain patients have a greater risk for chronic CME, such as those with diabetic retinopathy, uveitis, or a history of CME in the other eye, Dr. Warren said. Dr. Warren reported in a 2010 study published in Retina a more aggressive treatment for chronic CME, involving intravitreal triamcinolone and an injection of bevacizumab (Avastin, Genentech, South San Francisco, Calif., USA). The 39 patients in the study were randomized to receive one of four topical NSAIDs or a placebo for 4 months. At weeks 12 and 16, patients who received NSAIDs, particularly nepafenac and bromfenac, had a significant reduction in retinal thickness compared with those who received the placebo. EW Editors’ note: Dr. Devgan has financial interests with Alcon, Ista Pharmaceuticals, and Bausch + Lomb (Rochester, NY, USA). Dr. Warren has financial interests with Alcon, Dutch Ophthalmic Research Center (Zuidland, The Netherlands), and Genentech. Dr. Verdier has no financial interests related to this article. Contact information Devgan: 800-337-1969, devgan@gmail.com Verdier: 616-949-2001, daverdier@aol.com Warren: kwarren@warrenretina.com Chul Young CHOI, MD Assistant Professor, School of Medicine, Sung Kyun Kwan University Cornea & Refractive Surgery Services, Department of Ophthalmology, Kangbuk Samsung Hospital 108 Pyoung Dong, Jongno-Ku, Seoul, Korea, 110-746 Tel. no. +82-2-2001-2444 Fax no. +82-2-2001-2262 sashimi0@naver.com P seudophakic cystoid macular edema (PCME) is a common cause of unexpected visual loss after cataract surgery for more than 20 years. Despite how surgical techniques and devices in cataract surgery have developed, it is still commonly encountered. Although the pathogenesis of PCME is not fully understood, post-surgical inflammation with various mediators such as prostaglandins and leukotrienes is thought to be a major factor. Risk factors associated with PCME are age, vitreous loss or incarceration, dislocated intraocular lens, active uveitis, diabetes, and previous history of contralateral CME. Topical nonsteroidal anti-inflammatory drugs (NSAIDs) are well-tolerated and effective in prophylaxis and treatment. Topical administration of ketorolac, diclofenac, and newer NSAIDs (e.g., bromfenac, nepafenac) is now available for the prevention of PCME. Oral NSAIDs including COX-2 inhibitors (e.g., valdecoxib, rofecoxib) are used for prophylaxis and treatment off-label, but we should be aware of systemic side effects. Also, a pilot study (Soheilian et al. Retina 2010;30:509-515) provided promising results with a single dose of intravitreal diclofenac for the treatment of PCME, but with concerns regarding the effect and safety of intravitreal injection of NSAIDs for PCME. Corticosteroids are also commonly used in the treatment of PCME and can be administered in various ways. And combination with corticosteroids shows more efficacy than using either drug alone. However, the use of corticosteroids is limited, with the potential risks of elevated intraocular pressure and endophthalmitis. Carbonic anhydrase inhibitors (acetazolamide) may help to resorb the fluid from the subretinal space across the retinal pigment epithelium, but there is no randomized controlled study supporting the positive effects of carbonic anhydrase inhibitors on the prophylaxis or treatment of PCME. Recent studies have shown that anti-vascular endothelial growth factor (VEFG) agents such as bevacizumab are effective and well-tolerated in refractory PCME patients, but the role of intravitreal anti-VEGF in the treatment of PCME is not proven yet. In some chronic cases, vitrectomy may be indicated to remove vitreomacular adhesion and various inflammatory mediators from the vitreous cavity. Although routine prophylaxis with topical NSAIDs may provide additional protection from undesirable posterior problems, we should recognize the potential side effects of drugs and the natural course of PCME. Because many patients with PCME (up to 80%) spontaneously resolve without treatment, selective prophylaxis with topical NSAIDs for higher risk patients may be more reasonable. Editors’ note: Dr. Choi has no financial interests related to his comments. Views from Asia-Pacific Preventing - from page 49