Eyeworld

62 | EYEWORLD | DECEMBER 2020 ATARACT C References 1. Modjtahedi BS, et al. Periop- erative topical nonsteroidal anti-inflammatory drugs for macular edema prophylaxis following cataract surgery. Am J Ophthalmol. 2017;176:174–182. 2. Hoffman RS, et al. Cataract surgery and nonsteroidal anti- inflammatory drugs. J Cataract Refract Surg. 2016;42:1368–1379. Relevant disclosures Saidel: EyePoint Pharmaceu- ticals, Sun Pharma, Bausch + Lomb Savetsky: EyePoint Pharmaceu- ticals, Novartis, Allergan Walter: Omeros, Sun Pharma Whitman: None Contact Saidel: msaidel@yahoo.com Savetsky: msavetmd@gmail.com Walter: kwalter@wakehealth.edu Whitman: whitman@keywhitman.com When Omidria (phenylephrine and ketoro- lac intraocular solution 1%/0.3%, Omeros) be- came available, Dr. Walter said he began using this combined with topical bromfenac. He found this combination allows him to achieve a "near zero CME rate." Dr. Walter said that bromfenac specifically is the most potent at preventing CME when used properly for 30 days. Why his push for reduced steroid use? Dr. Walter pointed out that ophthalmology is the only surgical specialty that puts steroids on a postop wound. "Steroids delay wound healing, increase risk of infection, and, in our case, can cause a drastic rise in IOP," he said. "Most studies com- paring steroids and NSAIDs have concluded that the two together are 'synergistic' and should both be used, but they only include two arms in the study. One arm is steroids alone and the other is steroids plus an NSAIDs. What about the NSAID alone arm? It's typically not there. So those studies are invalid, as I think that the 'synergy' is all from the NSAID. "Some have claimed a steroid is needed for prevention of corneal edema," Dr. Walter continued. "I find the data on this to be weak. When you look at all FDA studies where NSAIDs gain approval for postop cataract pain, the adverse events for corneal edema are less than 2% in the NSAID alone arm. My experience has been it doesn't make any difference." Overall, when it comes to cataract anti-in- flammatory regimens, Dr. Saidel said doctors need to consider several factors: cost, outcome, and patient ease and compliance. "Cost reductions can be achieved using compounded drops. That is also something that will increase patient compliance. … In terms of administering the medication, whether in drop form or intraocular, you get fantastic patient compliance with intraocular injection of drugs. Because we know that patient compliance is so closely related to outcomes, that should be a strong motivator for any surgeon to consider providing that in their regimen." option at the moment, Dr. Whitman said, is that despite its current pass-through status, some insurers are not accepting it, creating more work for the billing staff. Dr. Whitman also said his staff is looking at the rescue rate of Dexycu compared to Dextenza (dexamethasone oph- thalmic insert 0.4 mg, Ocular Therapeutix). "We'd like to use whatever is most success- ful in the eye. Also, all of these are steroids, not antibiotics, so you have to put the patient on an antibiotic as well," he noted. What hasn't changed over the years are the reasons for using an NSAID. However, the liter- ature conflicts as to whether one is necessary. A large, retrospective study by Modjtahedi et al. found that topical NSAIDs were associated with only a modest decrease in postoperative macu- lar edema. 1 "The risk for PME is low and the number of patients benefiting from treatment is small," Modjtahedi et al wrote. In contrast, the literature review by Hoff- man et al. describes NSAIDs as "an important adjunctive tool for surgeons performing routine and complicated cataract surgery." 2 Dr. Savetsky said there are reasons other than CME prevention to use NSAIDs. "If it prevents CME in more patients than not, it's a nice additive," Dr. Savetsky said. "I like the NSAID because I think they are particu- larly good at pain control versus corticosteroids. When you prescribe an NSAID and steroid, you then have a synergistic effect, where you hit two different areas of the inflammatory pathway. "Prevention of miosis is another benefit, but mostly I think of pain and the synergy with a steroid," he continued. "My objective is to get rid of the inflammation quickly, so the better I can do that, the better the comfort of the pa- tients, and potentially a better outcome." Dr. Saidel also noted the benefit of NSAIDs for pain. "For me, that's where NSAIDs shine in maintaining patient comfort," he said. Up until 10 years ago, Keith Walter, MD, was only using an NSAID without a steroid. "I think we have seen that steroids alone aren't the best answer to prevent CME. We need to have an NSAID on board to help prevent CME and lessen pain and inflammation," Dr. Walter said. continued from page 60

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