Eyeworld

EW CATARACT 26 April 2014 by Maxine Lipner Getting the scoop on NSAIDs for cataract surgery W hen it comes to cataract surgery, NSAIDs today play an integral role, with most practitioners routinely incorporating them into their surgical regimens. Here is what leading practitioners told EyeWorld about their use of NSAIDs for phacoemulsification cases. With patients looking for premium outcomes, Eric D. Donnenfeld, MD, clinical professor of ophthalmology, New York Univer- sity Medical Center, stressed that he uses NSAIDs in every cataract case. "The evidence shows that with- out the use of NSAIDs, there's about a 5% incidence of macular thicken- ing that can be visually significant in patients," he said. "That not only can reduce Snellen visual acuity, but also reduces quality of vision, and steroids alone don't prevent this in every case." Eye on inflammation NSAIDs work to forestall any inflam- mation that may result from the surgery. "NSAIDs inhibit the produc- tion of prostaglandins, which begins the inflammatory cascade that leads to cystoid macular edema (CME) in susceptible patients," Dr. Donnenfeld explained. Nick Mamalis, MD, professor of ophthalmology, John A. Moran Eye Center, University of Utah, Salt Lake City, also uses NSAIDs in most cataract cases to help calm postoper- ative inflammation. "What NSAIDs do is they help to more quickly reestablish the blood aqueous barrier in the anterior segment," Dr. Mamalis said. "The quicker you can calm the inflammation and get the blood aqueous barrier reestablished, the better you can prevent sequelae of inflammation." He pointed out that NSAIDs have been shown to help decrease the incidence of CME following cataract surgery. Elizabeth A. Davis, MD, managing partner, Minnesota Eye Consultants, and adjunct clinical professor, University of Minnesota, Twin Cities, Minn., said that in addition to reducing the incidence of CME, NSAIDs can have other benefits. "I do think they comple- ment the anti-inflammatory activity in the anterior segment of the steroid," she said, noting that this can ultimately make for faster visual recovery. NSAIDs in action While the consensus here is to include NSAIDs in nearly all cases, the regimens employed vary. Dr. Donnenfeld stressed the need to get NSAIDs on board early. "Since we know that NSAIDs work by prohibiting the production of prostaglandins and don't affect the existing prostaglandins, I believe that it's important to pretreat these patients," he said. "Treating them the day of surgery doesn't give you sufficient anti-inflammatory effects, so I start my NSAIDs preoperatively." When possible, Dr. Donnenfeld chooses to start NSAIDs 3 days before surgery, but noted that even beginning these 1 day beforehand can make a big difference. He cited a September 2006 Journal of Cataract & Refractive Surgery study that he led that showed a negligible effect of adding NSAIDs an hour before sur- gery. "We get a very good effect with 1 day and a little bit better effect with 3 days," Dr. Donnenfeld said. "Anywhere between 1 and 3 days (preoperatively) would be the right answer from my perspective." In routine cases, Dr. Donnenfeld continues these for 1 month postop. For high-risk patients, he recom- mends starting them on NSAIDs 1 week beforehand and continuing usage for 2 to 3 months postop, de- pending on the case. "For example, patients with epiretinal membranes are not as high a risk as those with proliferative diabetic retinopathy," Dr. Donnenfeld said. "For a patient with proliferative diabetic retinopa- thy, we start a full week before and go 3 months postoperatively." In addition, he carefully moni- tors these patients to see if they need intravitreal injections of anti-VEGF or steroids, depending on the retinal complication. He prefers the newer generation NSAIDs such as Prolensa (brom- fenac, Bausch + Lomb, Rochester, N.Y.) and Ilevro (nepafenac, Alcon, Fort Worth, Texas), which are ex- tremely potent, with a much better effect than older generation NSAIDs, he said. "They're reformulated to achieve additional penetration into the eye. They're also very gentle on the ocular surface." This, he finds, can play a major role from a patient compliance perspective. In addition, particularly for those with ocular surface toxicity, Dr. Donnenfeld believes that the once-a-day dosing of these agents coupled with their buffered vehicles can reduce the risk of keratitis and corneal melting. Sonia H. Yoo, MD, professor of ophthalmology, Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, likewise starts patients on NSAIDs 2 to 3 days preop and has had them continue until the bottle is empty—typically 2 to 4 weeks. She, however, typically uses the generic NSAIDs, dosed 4 times a day. "Since I use a corticos- teroid, which I dose 4 times a day anyway, patients know to take both of them the same number of times, so it makes it easier," she said. "But for patients who have a vulnerable ocular surface where I think that the burning issue is going to be prob- lematic or if I'm concerned about compliance, I might choose a branded NSAID." In cases where patients are using generics, Dr. Yoo makes a point of letting them know that they might have some temporary burning upon installation. "That way they won't be afraid that they have something wrong or that they have some kind of allergy to the drops," she said. Dr. Davis routinely starts her patients on Prolensa on the day of cataract surgery, while they are in the preoperative area. "I don't have them start it at home unless there's a greater risk for macular edema, like diabetes or an epiretinal membrane," she said. In such high-risk cases, Dr. Davis will start patients on the NSAID 1 week before surgery and continue for 6 weeks postoperatively. She has found that her routine regimen, which also includes Vigamox (moxifloxacin, Alcon) and Pred Forte (prednisolone, Allergan, Irvine, Calif.) each 4 times a day, is effective. "Overall my incidence of CME with that regimen is very low," she said. "I find the more that you do in terms of complicating any medical Pharmaceutical focus NSAIDS can knock down inflammation and potentially stave off a case of CME such as this one. Source: Phillip Rosenfeld, MD

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