EyeWorld India June 2017 Issue

June 2017 EWAP SECONDARY FEATURE 33 High-risk and special patient populations In certain patient groups, the benefits of NSAID use associated with cataract surgery may not have an abundance of evidence, but surgeons feel strongly that it could help cut the risk for CME. This includes patients with diabetes; in fact, the European Society for Cataract and Refractive Surgeons is leading a multicenter trial called PREMED (PREvention of Macular EDema after cataract surgery) to assess the better prophylactic regime for this group, Dr. Kessel said. Other patients considered high risk who may benefit from NSAIDs include those with previous retinal vein occlusions, those with epiretinal membranes, and those with uveitis, Dr. Kessel said. Based on his research, Dr. Kim is still a little skeptical about the need for NSAIDs. “In diabetic patients, there may be some small benefit because of their higher risk and prevalence, but the evidence is inconsistent and not robust. In uveitis patients, there is no compelling evidence that they have a role since they have a much weaker anti-inflammatory effect when compared to corticosteroids that have adequate intraocular penetration,” he said. Dr. Myers also favors the possible use of NSAIDs in patients with diabetic macular edema that is already present and vitreous macular traction. One emerging patient group that may push surgeons to prescribe NSAIDs is those receiving premium IOLs, Dr. Sheppard said. “These patients have skyrocketing demands and expectations. The last thing you want to have is a patient paying cash who then has postop visual degradation due to edema. Most doctors feel that once you add edema, things like contrast sensitivity are compromised, even if the visual acuity is 20/20,” he said. Although Dr. Myers is not a big fan of multifocal premium IOLs, he also sees this as a group that may be more likely to receive NSAIDs. “The patient is paying a lot of money, so they probably don’t mind buying another bottle. But for routine cataract surgery, I don’t think this makes a major difference,” he said. Analyzing dosing and agents There also are different approaches regarding dosing for NSAIDs, with the basic conclusion that ideal dosing for NSAIDs is not clear. “The [U.S.] Food and Drug Administration [FDA] labeling says 1 day preop and 2 weeks postop, but that doesn’t mean some doctors don’t adapt for personal preference,” Dr. Sheppard said. “In the context of normal cataract surgery, many doctors feel 2 weeks postop is good for pain and inflammation. On the other hand, off-label use is somewhat up in the air because of the lack of FDA studies.” “Topical NSAIDs are more effective when started before surgery, although just how long before surgery is not clear,” Dr. Dunn said. “If one follows the same principles that apply for corticosteroids, it probably makes the most sense to start topical NSAIDs at least several days before surgery, rather than just prior to surgery or after surgery has been completed.” “At my institution, treatment begins 3 days prior to surgery, and the patients use one bottle of eye drops per eye, for approximately 3 to 4 weeks of treatment postop,” Dr. Kessel said. Surgeons also generally lean toward less frequent dosing—such as the once-daily formulations— for better compliance and to cut down on any NSAID risk factors. “Reduced dosing decreases the total exposure of the cornea to drug and vehicle, so the risks decrease,” Dr. Kim said. To add to the decision-making mix, there are now FDA-approved intracameral NSAIDs in the U.S., potentially making compliance and administration easier. It’s not yet clear if some NSAID agents work better than others because there is a lack of good clinical trials for this area. One recent meta-analysis focusing on topical NSAID safety found that topical piroxicam had fewer adverse effects than bromfenac, diclofenac, flurbiprofen, ketorolac, and nepafenac, but the quality of evidence was low, according to researchers. 4 Topical NSAID risks Another reason surgeons remain vigilant about NSAID use is because of uncommon but still very real risk factors. These can include rare reports of corneal melting and allergic reactions, Dr. Kim said. However, corneal melting was more common in older and generic NSAIDs, Dr. Sheppard added. Dr. Kessel’s meta-analysis of 446 patients randomized to receive NSAIDs found no reports of corneal melting. 3 There are also possible effects on the ocular surface. “Both the drug itself and the preservatives in the bottle may precipitate or worsen ocular surface disease,” Dr. Dunn said. One concern Dr. Sheppard has is the switch from a brand name prescription to a generic, which may be associated with greater risks for patients. “The frightening aspect is when a doctor prescribes a branded topical NSAID, and the pharmacist replaces it with a generic. The doctor doesn’t know about this until the postop healing phase,” he said. For this reason, Dr. Sheppard is very cautious about the use of NSAIDs in patients with autoimmune diseases or limbal stem cell deficiency, who may be more prone to corneal melts. A role for oral NSAIDs? Patients are accustomed to popping oral NSAIDs when they have pain or inflammation—so does this type of medicine have a role in cataract surgery, in addition to topical NSAIDs? “There potentially could be, but we don’t have evidence to demonstrate this,” Dr. Kim said. “We do know oral NSAIDs are much less effective in getting into the anterior chamber of the Weighing – from page 31 continued on page 34