Eyeworld

EW CATARACT 22 February 2019 Pharmaceutical focus by Maxine Lipner EyeWorld Senior Contributing Writer Postoperatively, Dr. Dhaliwal holds off on prescribing the NSAID. "For the first week postop, I do not use an NSAID. I just use a steroid because they're on enough drops and I want to make sure that any epithelial defect is healed," she said. "I don't want to bombard their epithelial surface with anything that could delay restoration of a smooth ocular surface. There have been sev- eral reports of corneal melting when NSAIDS are used in compromised corneas." Dr. Dhaliwal sees patients at the 1-week postoperative mark to make sure that they are doing well. If they are, she adds the NSAID and recommends that a routine patient use this until the bottle is empty and a high-risk patient continue to use this for 8 weeks. However, if someone has a compromised cornea with a persistent epithelial defect, Dr. Dhaliwal will forgo the NSAID entirely. Richard Stiverson, MD, Den- ver, takes what he terms a selective approach to NSAID use, reserving this only for those at high risk for CME. The incidence of CME after uncomplicated cataract surgery in a patient who has no risk factors is just 1%, he pointed out. "Of that 1 in 100 who have CME with uncom- plicated surgery and no risk factors 80% of those patients' CME will re- solve on its own with no treatment at all," he said. He thinks those who give all patients an NSAID may be unnecessarily treating 99 out of 100 patients who have cataract surgery. With some of the NSAIDs costing well over $100 per bottle, this can result in a hefty cost burden. "I use it any time that I've had a surgery where there's a compli- cation and for refractive cataract surgery," Dr. Stiverson said. "They're paying extra money out of pocket for a refractive outcome, for as good vision as possible without glasses." Also, if someone has had a capsule rupture, iris trauma, or if the surgery took longer than expected, he puts the patient on an NSAID, as well as anyone with diabetic retinopathy within the macular region, uveitis, CME in the fellow eye, or other high-risk patients. In such cases, Dr. Stiverson noted that practitioners use either ketorolac or diclofenac. "When we use it, it's always QID dosing," such cases: pain control, improved dilation, and reduced risk of cystoid macular edema (CME). "Certainly, if you have a diabetic patient who has poor pupillary dilation and a complex cataract, they're at higher risk for macular edema," Dr. Don- aldson said. Dr. Donaldson's own regimen is to use NSAIDs for all of her cataract patients. "My preferred prescribing regimen is to use branded drops instead of the generics because I can use those less frequently," she said. "Generally, I use Ilevro [nepafenac, Novartis, Basel, Switzerland], and I can do that one time a day." Dr. Donaldson starts the NSAID 3 days before surgery, mostly to help with pupillary dilation, and continues pa- tients on this for 1 month postop. In some cases, she might keep patients on the regimen longer if they have preexisting macular ede- ma in that eye or CME in the other eye. The exception would be if there was something unique about the first eye such as a trauma, she noted. She does not use the intraoper- ative NSAID Omidria (phenyleph- rine/ketorolac, Omeros, Seattle), since her hospital-based practice has not yet allowed surgeons to obtain it for financial reasons. If given the opportunity, she said she would use it since it has been shown to help pupils remain dilated as well as improve comfort during the sur- gery and in the early postoperative period. Deepinder K. Dhaliwal, MD, University of Pittsburgh School of Medicine, prescribes NSAIDs for all of her cataract patients. She finds the newer NSAIDs preferable but knows that these are sometimes cost prohibitive. Her preference is for agents such as bromfenac (BromSite, Sun Pharmaceutical, Mumbai, India) and nepafenac because the frequen- cy of instillation is less and the molecules penetrate better inside the eye. While this makes it easier for the patient, if it is not affordable, she will instead prescribe the generic NSAID ketorolac. Dr. Dhaliwal's regimen varies depending on the patient. In a high- risk patient with a CME issue or an epiretinal membrane, she starts them on the NSAID 1 week ahead of time. Meanwhile, for routine patients, she begins the medication just 1 hour ahead of time. Plantation, Florida. "However, there are some surgeons who have gotten away from drops entirely and are doing various forms of injections. However, the majority are still using drops including a nonsteroidal," Dr. Donaldson said. She noted there are three main reasons for using an NSAID in Surgeons share how they use NSAIDs W hen it comes to NSAIDs, most people in the U.S. use them in cataract cases, said Kendall Donaldson, MD, Bascom Palmer Eye Institute, Eyes on NSAIDs for cataract surgery Pupillary miosis associated with femtosecond laser-assisted cataract surgery can be limited through preoperative treatment with topical NSAIDs. Source: Kendall Donaldson, MD

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