Eyeworld

36 | EYEWORLD | OCTOBER 2020 on the cornea, Dr. Vann continued, adding that with this in mind it can be helpful to keep inci- sions as small as possible. Dr. Vann said he's now using an intraoper- ative aberrometer to help address astigmatism. "Typically, we'll bring the pressure up to physi- ologic, so that it's a normal 15–20 mm Hg, then we'll take a reading of the aphakic refraction so it can tell us what the astigmatism is," Dr. Vann said. This also takes into account the posterior cornea and the impact of the main incision that might otherwise limit success. In Dr. MacDonald's view, all cataract sur- geons, even in developed countries, should be comfortable with small incision cataract surgery. There will likely be a time when the best choice for patient safety and quality may be small incision cataract surgery, Dr. MacDonald said. "If you don't have confidence in that skillset, you are more likely to say, 'I can phaco every- thing,'" she said, adding that the small incision technique can avoid damage to the cornea in complex cases. To learn MSICS properly, Dr. MacDon- ald recommended taking a course. "It's great to learn pearls from other surgeons who are experts in the field," she said. Going forward, a new technology is being developed by Carl Zeiss Meditec that will remove the nucleus without any phaco energy, which Dr. MacDonald thinks will help as well. "I think using technology that is being devel- oped will allow us to bring small incision sur- gery to all who need it without fear of damag- ing the nucleus," Dr. MacDonald concluded. continued from page 35 by Maxine Lipner Contributing Writer Use of NSAIDs and corticosteroids to stave off CME W hile physicians agree that pre- vention of CME after cataract surgery is important, how to prevent it can be a point of con- tention. The idea of using an NSAID alone received a boost from a recent study, with results indicating that bromfenac had lower CME rates than three other regimens. 1 The retrospective review included four dif- ferent regimens from surgeons at Wake Forest University. For three of these regimens, differ- ent combinations of generic and brand name NSAIDs and steroids were used, said Keith Walter, MD, adding that the fourth involved use of the bromfenac alone. This regimen had a CME rate of 0.09% vs. the overall rate of 0.82%, Dr. Walter reported. Dr. Walter said he has relied on an NSAID-only approach since 2009. He often found himself having to write an extra pre- scription for the nonsteroidal after he stopped receiving it in a free sample kit he had been offering patients. "I thought bromfenac in par- ticular is a good NSAID, which at that time was just twice a day," he said. This dosing schedule was more enticing than asking patients to take drops 4–6 times a day with a complicated taper- ing schedule, he said. However, not all NSAIDs are the same, he stressed. The generic ketorolac, for example, needs to be taken 4 times a day, which can be difficult for patients to comply with for more than a couple of weeks since this can lead to dryness as well as some toxicity issues. Dr. Walter only adds a steroid in those rare cases where patients have a lot of symptom- atic cell and flare. "If you have some retained cortex or retained lens fragment, you might see extra inflammation for that reason," he said. While there is some literature that shows a benefit to using both agents, often studies don't include an arm showing the effect of using an NSAID alone, Dr. Walter said. He views the European PREMED study, which looked at bromfenac vs. a steroid, as poorly designed because bromfenac was only administered for 2 weeks postoperatively. 2 This is not adequate for the prevention of CME, which usually spikes around 4 weeks postoperatively, Dr. Walter said. About the doctors Kevin M. Miller, MD Kolokotrones Chair in Ophthalmology David Geffen School of Medicine at UCLA Los Angeles, California William Trattler, MD Director of Cornea Center for Excellence in Eye Care Miami, Florida Keith Walter, MD Professor of Ophthalmology Wake Forest University Winston-Salem, North Carolina References 1. Walter KA, et al. Incidence of cystoid macular edema following routine cataract surgery using NSAIDs alone or with cortico- steroids. Arg Bras Oftalmol. 2020;83:55–61. 2. Wielders LPH, et al. European multicenter trial of the prevention of cystoid macular edema after cataract surgery in nondiabetics: ESCRS PREMED study report 1. J Cataract Refract Surg. 2018;44:429–439. 3. Wittpenn JR, et al. A random- ized, masked comparison of topical ketorolac 0.4% plus ste- roid vs steroid alone in low-risk cataract surgery patients. Am J Ophthalmol. 2008;146:554–560. Relevant disclosures Miller: None Trattler: Alcon, Bausch + Lomb, Kala, Johnson & Johnson, Novartis, Omeros, Sun Pharma Walter: Omeros, Sun Pharma continued on page 38 RESEARCH HIGHLIGHT ATARACT C

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