EyeWorld Asia-Pacific September 2014 Issue

September 2014 65 EWAP PHARMACEUTICALS NSAIDs can knock down inflammation and potentially stave off a case of CME such as this one. Source: Phillip Rosenfeld, MD Getting the scoop on NSAIDs for cataract surgery by Maxine Lipner EyeWorld Senior Contributing Writer NSAIDs play an integral role in cataract surgery today W hen it comes to cataract surgery, NSAIDs today play an integral role, with most practitioners routinely incorporating them into their surgical regimens. Here is what leading practitioners told EyeWorld about their use of NSAIDs for phacoemulsification cases. With patients looking for premium outcomes, Eric D. Donnenfeld, MD , clinical professor of ophthalmology, New York University Medical Center, NY, U.S., stressed that he uses NSAIDs in every cataract case. “The evidence shows that without the use of NSAIDs, there’s about a 5% incidence of macular thickening that can be visually significant in patients,” he said. “That not only can reduce Snellen visual acuity, but also reduces quality of vision, and steroids alone don’t prevent this in every case.” Eye on inflammation NSAIDs work to forestall any inflammation that may result from the surgery. “NSAIDs inhibit the production of prostaglandins, which begins the inflammatory cascade that leads to cystoid macular edema (CME) in susceptible patients,” Dr. Donnenfeld explained. Nick Mamalis, MD , professor of ophthalmology, John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, U.S., also uses NSAIDs in most cataract cases to help calm postoperative inflammation. “What NSAIDs do is they help to more quickly reestablish the blood aqueous barrier in the anterior segment,” Dr. Mamalis said. “The quicker you can calm the inflammation and get the blood–aqueous barrier reestablished, the better you can prevent sequelae of inflammation.” He pointed out that NSAIDs have been shown to help decrease the incidence of CME following cataract surgery. Elizabeth A. Davis, MD , managing partner, Minnesota Eye Consultants, Minn., U.S., and adjunct clinical professor, University of Minnesota, Twin Cities, Minn., U.S., said that in addition to reducing the incidence of CME, NSAIDs can have other benefits. “I do think they complement the anti-inflammatory activity in the anterior segment of the steroid,” she said, noting that this can ultimately make for faster visual recovery. NSAIDs in action While the consensus here is to include NSAIDs in nearly all cases, the regimens employed vary. Dr. Donnenfeld stressed the need to get NSAIDs on board early. “Since we know that NSAIDs work by prohibiting the production of prostaglandins and don’t affect the existing prostaglandins, I believe that it’s important to pretreat these patients,” he said. “Treating them the day of surgery doesn’t give you sufficient anti- inflammatory effects, so I start my NSAIDs preoperatively.” When possible, Dr. Donnenfeld chooses to start NSAIDs 3 days before surgery, but noted that even beginning these 1 day beforehand can make a big difference. He cited a September 2006 Journal of Cataract & Refractive Surgery study that he led that showed a negligible effect of adding NSAIDs an hour before surgery. “We get a very good effect with 1 day and a little bit better effect with 3 days,” Dr. Donnenfeld said. “Anywhere between 1 and 3 days (preoperatively) would be the right answer from my perspective.” In routine cases, Dr. Donnenfeld continues these for 1 month postop. For high- risk patients, he recommends starting them on NSAIDs 1 week beforehand and continuing usage for 2 to 3 months postop, depending on the case. “For example, patients with epiretinal membranes are not as high a risk as those with proliferative diabetic retinopathy,” Dr. Donnenfeld said. “For a patient with proliferative diabetic retinopathy, we start a continued on page 66