EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/111385
February 2013 EW NEWS & OPINION 21 Pharmaceutical focus Dousing cataract surgical inflammation with steroids and NSAIDs by Maxine Lipner Senior EyeWorld Contributing Writer How practitioners are using these to optimize outcomes M any cataract practitioners today are beating back potential inflammation related to cataract surgery even before it can arise with NSAIDs and steroids. Indeed, all of the surgeons EyeWorld spoke with routinely use these drugs for every cataract case. But even with that decision made, practitioners must still contend with regimen nuances, issues of generic drug substitutions, economic realities for patients, and more. Nick Mamalis, M.D., professor of ophthalmology, John A. Moran Eye Center, Department of Ophthalmology & Visual Sciences, University of Utah, Salt Lake City, diligently uses steroids and NSAIDs for all of his cataract patients. ���We found that the steroids work well in calming post-operative inflammation, they help to speed up the reestablishment of the blood aqueous barrier following cataract surgery, and can decrease inflammation overall,��� he said. In addition, the NSAIDs help to decrease the chance of inflammation causing cystoid macular edema (CME). Likewise, for Sonia H. Yoo, M.D., professor of ophthalmology, Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, steroids and NSAIDs are an integral part of her cataract protocol. ���I think that the steroids and NSAIDs have been shown to greatly reduce discomfort and inflammation after surgery,��� she said. ���At least in theory it makes sense to suppress that feedback loop of inflammation before it starts.��� Accordingly, Dr. Yoo routinely starts her patients on NSAIDs prior to cataract surgery. With steroids she begins this after surgery and then tapers it over the course of a month. For Elizabeth A. Davis, M.D., managing partner, Minnesota Eye Consultants, and adjunct clinical professor, University of Minnesota, Twin Cities, Minneapolis, using these anti-inflammatory drugs for cataract surgery is a no-brainer. ���The reason is that I can���t always predict who���s going to get CME,��� she said. ���Since it can be so significant and devastating and has a higher inci- Since there is no predicting who may get CME, as seen in this patient, many practitioners routinely use NSAIDs prior to cataract surgery. Source: Elizabeth A. Davis, M.D. dence of impacting vision than endophthalmitis, and it���s the standard-of-care to prescribe an antibiotic for endophthalmitis, I think that it makes even more sense to routinely prescribe a combination steroid/nonsteroidal.��� Regimen realities Eric D. Donnenfeld, M.D., clinical professor of ophthalmology, New York University, New York, swears by the use of anti-inflammatory drugs. ���Every single patient receives steroids and NSAIDs when I perform cataract surgery,��� he said. ���The only difference is the dosing pattern varies depending upon the patients coming in for surgery.��� For example, since diabetics have heightened CME risk, Dr. Donnenfeld is particularly cautious with such patients, referring those with edema to a retinal specialist. If they don���t have macular edema he proceeds but treats them more ag- gressively. ���I start my nonsteroidal a week before cataract surgery, and I pretreat them with corticosteroids as well,��� Dr. Donnenfeld said. ���My pretreatment regimen is to use difluprednate in a pulsed dose every 15 minutes for seven doses before cataract surgery and then to treat them for longer periods of time post-operatively.��� For diabetic patients, Dr. Donnenfeld will continue use of nonsteroidal medication for two months and use steroids for a month. In cases where these diabetic patients have other risk factors, Dr. Donnenfeld continues them on nonsteroidal medication for a minimum of three months and the steroid for six weeks. Dr. Mamalis is also more aggressive with medication in diabetic patients. He will start these diabetic patients on NSAIDs three days prior to surgery, something he typically holds off on in straightforward cases. ���A lot of my colleagues will start NSAIDs routinely one day or three days before surgery,��� Dr. Mamalis said. ���But I found in my routine patients we give them the NSAIDs as they come to the OR or the surgical center for surgery and give them (the medication) the same day.��� Post-op, he keeps such diabetic patients on NSAID drops for anywhere from four to eight weeks. By contrast, he keeps his routine patients on NSAIDs for just two to four weeks. Meanwhile, if patients develop CME, Dr. Donnenfeld believes that they should receive the strongest possible treatment topically to begin with. ���I use a topical nonsteroidal,��� Dr. Donnenfeld said. ���I believe that all of the branded nonsteroidals that are currently available are excellent���Acuvail [ketorolac 0.45%, Allergan, Irvine, Calif.], Bromday [bromfenac 0.09%, Bausch + Lomb, Rochester, N.Y.], and Nevanac [nepafenac 0.1%, Alcon, Fort Worth, Texas].��� When it comes to use of corticosteroids in these CME cases, Dr. Donnenfeld sees a significant difference between difluprednate and prednisolone acetate. ���That���s where I will absolutely move patients over to difluprednate, which is my steroid that I recommend for all cataract surgery,��� he said. ���I will put them on difluprednate four times a day rather than twice a day, which is my normal dosing schedule.��� He then re-evaluates them at two weeks and if they are not showing signs of clinical improvement, he will refer them to a retina specialist. If they do show signs of clinical improvement he puts them on a dose of nonsteroidal medication for two months and tapers the steroid down over a four- to six-week period. Meanwhile Dr. Davis advised using Pred Forte (prednisolone, Allergan) four times a day and bromfenac twice a day in CME patients. If no improvement is seen Dr. Davis will refer the patient to a retina specialist to potentially provide an intraocular injection or in the worst-case scenario, perform a vitrectomy. The generic question Deciding which NSAIDs a patient should get may depend on their continued on page 22