EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/387844
Inflammation-associated postoperative pain results in dissatisfied patient by Sonia H. Yoo, MD The true impact of ocular inflammation on refractive cataract surgery outcomes Sonia H. Yoo, MD Reducing the impact of cataract surgical stress by mitigating inflammation and reducing ultrasound energy T he physical trauma associat- ed with ocular surgery can induce an inflammato y response that affects the entire eye. Inflammation on the cornea generates prostaglandins (caused by initiating the arachidon- ic acid cascade) that activate both cyclooxygenase-1 and cyclooxygen- ase-2. 1 This cascade can manifest clinically as hyperemia, miosis, impaired vision, or diminished visual acuity secondary to cystoid macular edema (CME) in more severe cases. 1,2 Subjective complaints can range from pain to photopho- bia. 3 Phacoemulsification typically does not result in significant inflammation, but some patients are at higher risk and will experience some form of postoperative infla - mation. 4,5 For the typical cataract patient, what had been acceptable postop vision (20/40) years ago is no longer acceptable, especially in the premi- um IOL patient population. 3 For this group, any postop incident that can reduce visual acuity (even if tran- sient) is considered a failure on the part of the surgeon to deliver the best care possible. Factors influencing postop inflammation The higher the density level of cataract, the greater the likelihood for inflammatio 6 (see Figure 1). Iris pigmentation is another factor; a primary reason anterior segment surgeons use NSAIDs postop is for CME prophylaxis. (See Table 2 for the list of recently approved NSAIDs and steroids.) References 1. Fung D, Cohen MM, Stewart S, Davies A. What determines patient satisfaction with cat- aract care under topical local anesthesia and monitored sedation in a community hospital setting? Anesth Analg. 2005;100(6):1644–50. 2. ASCRS Clinical Survey 2013. Global Trends in Ophthalmology. Fairfax, VA: American Soci- ety of Cataract & Refractive Surgery, 2013. 3. ASCRS Clinical Survey 2014. Global Trends in Ophthalmology. Fairfax, VA: American Soci- ety of Cataract and Refractive Surgery, 2014. 4. Streilein JW. Ocular immune privilege: the eye takes a dim but practical view of immunity and inflamm tion. J Leukoc Biol. 2003;74(2):179–85. 5. Nevanac [package insert]. Fort Worth, Texas: Alcon Laboratories Inc., 2008. 6. Bromday [package insert]. Irvine, CA: ISTA Pharmaceuticals, 2011. 7. Lotemax gel [package insert]. Tampa, FL: Bausch + Lomb Incorporated, 2012. 8. Ilevro [package insert]. Fort Worth, Texas: Alcon Laboratories Inc., 2013. 9. Lotemax [package insert]. Tampa, FL: Bausch + Lomb Incorporated, 2013. 10. Prolensa [package insert]. Tampa, FL: Bausch + Lomb Incorporated, 2013. 11. Durezol [package insert]. Fort Worth, Texas: Alcon Laboratories Inc., 2013. Dr. Kim is professor of ophthalmology, Duke University School of Medicine, and director of fellowship programs, cornea and refractive surgery services, Duke University Eye Center, Durham, N.C. continued from page 1 Figure 1. Cataract density, ranging in grade from 0 to 4+. As the cataract density increases from 0 (upper left corner) to 4+ (lower right corner), the risk of postoperative inflammation increases as well. Adapted from Chylack et al., 1993 10 Drug (active ingredient, manufacturer) Drug type Indication Dosing Ilevro 8 (nepafenac 0.3%, Alcon) NSAID Treatment of pain and inflamm tion associated with cataract surgery 1 drop day before surgery, day of surgery, and 14 days postoperatively; additional drop administered 30–120 minutes before surgery Prolensa 10 (bromfenac 0.07%, Bausch + Lomb) NSAID Treatment of postoperative inflamm tion and reduction of ocular pain in patients who have undergone cataract surgery 1 drop day before surgery, day of surgery, and 14 days postoperatively Lotemax gel 7 (loteprednol etabonate ophthalmic gel 0.5%, Bausch + Lomb) Corticosteroid Treatment of postoperative inflamm tion and pain following ocular surgery 1–2 drops 4 times daily beginning the day after surgery and continuing throughout the first 2 weeks of the postoper tive period Durezol 11 (diflupredn te 0.05%, Alcon) Corticosteroid Treatment of inflamm tion and pain associated with ocular surgery; treatment of endogenous anterior uveitis 1 drop 4 times daily beginning 24 hours after surgery and continuing throughout the first 2 postop weeks; 2 times daily for a week; then taper based on response Table 2. Anti-inflammato y drugs, 2013