EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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Supported by an unrestricted educational grant from Bausch + Lomb The anti-inflammato y effects of steroids are well known. 16,17 Although topical steroids seem to be more powerful than nonsteroidal anti-inflammato y drugs (NSAIDs), as the latter only inhibit cyclooxy- genase, steroids do have frequent, potentially dangerous side effects. NSAIDs, on the other hand, are well known for their extraordinary safety profile 16,17 A literature search recommended the prophylactic use of NSAIDs in combination with corticosteroids to prevent CME. 17 In this meta-analysis, the recommend- ed treatment is one drop 4 times daily the day before surgery and continuing for 4 weeks after surgery. (And one drop every 15 minutes in the hour immediately before sur- gery. 17 ) The preoperative treatment with NSAIDs followed by combined NSAID/steroid therapy postopera- tively is considered the "standard of care" in cataract surgery. 16 In my practice, I prefer to use a steroid (prednisolone acetate 1% or loteprednol), an antibiotic (moxifloxacin or trimethoprim polymyxin B), and ketorolac 0.5% four times daily in week 1, with a quick taper on the steroid to 3, 2, and 1 time daily in weeks 2–4. I stop the antibiotic after 1 week, and continue to have the patient use the NSAID 4 times daily until the bottle runs out. Postoperative pain: A continuum Postoperative pain complaints can vary from minor discomfort to "FTS" (patient "feels the stitches") to moderate-to-severe pain. The latter groups may have borderline ocular surface disease as well. Fung et al. evaluated 306 sub- jects undergoing cataract surgery to measure both pain and satisfaction levels during the immediate post- operative period (in the recovery room). 18 They found 37% of subjects reported mild-to-moderate postop pain, and 34% required oral pain medication to alleviate their symp- toms. Gender and cataract density were not significant determinants of postop patient satisfaction; preoper- ative anxiety and postoperative pain were. Any postoperative pain was the single most significant predictor of dissatisfaction with the subject's care. The greater the postop pain, the lower the rating for quality of the surgical experience. Summary Given the evidence that postop- erative inflammation slows visual recovery, it is our responsibility to do what we can to minimize infla - mation in order to maximize postop vision and speed recovery time. We know that nonsteroidal anti- inflammato y drugs and steroids are often used together to achieve those purposes. 19,20 References 1. Cho H, Wolf KJ, Wolf EJ. Management of ocular inflamm tion and pain following cata- ract surgery: focus on bromfenac ophthalmic solution. Clin Ophthalmol. 2009;3:199–210. 2. Flach AJ. The incidence, pathogenesis and treatment of cystoid macular edema following cataract surgery. Trans Am Ophthalmol Soc. 1998;96:557–634. 3. Burling-Phillips L. After cataract surgery: Watching for cystoid macular edema. EyeNet. San Francisco: American Academy of Ophthalmology, January 2007. 4. Gulkilik G, Kocabora S, Taskapili M, Engin G. Cystoid macular edema after phacoemulsifi- cation: risk factors and effect on visual acuity. Can J Ophthalmol. 2006;41(6):699–703. 5. Donnenfeld ED. Diflupredn te for the prevention of ocular inflamm tion postsurgery: an update. Clin Ophthalmol. 2011;5:811–6. 6. Martin KR, Burton RL. The phacoemulsifi- cation learning curve: preoperative complica- tions in the first 3000 cases of an experienced surgeon. Eye (Lond). 2000;14 (Pt 2):190–5. 7. Onodera T, Gimbel HV, DeBroff BM. Effects of cycloplegia and iris pigmentation on postoperative intraocular inflamm tion. Ophthalmic Surg. 1993;24(11):746–52. 8. Demirci G, Karabas L, Maral H, et al. Effect of air bubble on inflamm tion after cataract surgery in rabbit eyes. Indian J Ophthalmol. 2013;61(7):343–8. 9. Ventura MC, Ventura BV, Ventura CV, et al. Congenital cataract surgery with intracameral triamcinolone: pre- and postoperative central corneal thickness and intraocular pressure. J AAPOS. 2012;16(5):441–4. 10. Chylack LT, Jr., Wolfe JK, Singer DM, et al. The Lens Opacities Classific tion System III. The Longitudinal Study of Cataract Study Group. Arch Ophthalmol. 1993;111(6):831–6. 11. Johnson MW. Etiology and treatment of macular edema. Am J Ophthalmol. 2009;147(1):11–21 e1. 12. Sahin M, Cingu AK, Gozum N. Eval- uation of cystoid macular edema using optical coherence tomography and fundus autofluorescence after uncomplic ted phacoemulsific tion surgery. J Ophthalmol. 2013;2013:376013. 13. Ray S, D'Amico DJ. Pseudophakic cystoid macular edema. Semin Ophthalmol. 2002;17(3–4):167–80. 14. Gaynes BI, Fiscella R. Topical nonsteroidal anti-inflamm tory drugs for ophthalmic use: a safety review. Drug Saf. 2002;25(4):233–50. 15. Henderson BA, Kim JY, Ament CS, et al. Clinical pseudophakic cystoid macular edema. Risk factors for development and duration after treatment. J Cataract Refract Surg. 2007;33(9):1550–8. 16. Grob SR, Gonzalez-Gonzalez LA, Daly MK. Management of mydriasis and pain in cataract and intraocular lens surgery: review of current medications and future directions. Clin Ophthalmol. 2014;8:1281–9. 17. Quintana NE, Allocco AR, Ponce JA, Magurno MG. Non steroidal anti-inflamm tory drugs in the prevention of cystoid macular edema after uneventful cataract surgery. Clin Ophthalmol. 2014;8:1209–12. 18. 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. 19. Kim SJ, Flach AJ, Jampol LM. Nonsteroidal anti-inflamm tory drugs in ophthalmology. Surv Ophthalmol. 2010;55(2):108–33. 20. O'Brien TP. Emerging guidelines for use of NSAID therapy to optimize cataract surgery patient care. Curr Med Res Opin. 2005;21(7):1131–7. Dr. Yoo is professor of ophthalmology at the University of Miami Miller School of Medicine/ Bascom Palmer Eye Institute in Miami. Previous traditional cataract patient Today's cataract patient Retired Working Minimal to no driving Independent Not on a computer Uses cell phone, computer, tablet Expectation of recovery time Needs good functional vision as quickly as possible Needed glasses postop Pays for premium IOL Table 1. Changing patient needs. Patients expect cataract surgery to be "no big deal," with little pain and excellent postop day 1 vision. Any pain or reduced visual acuity equates to poor service and surgery on the part of the physician. Source: Sonia H. Yoo, MD patients with darker irides are more prone to postop inflammation 7 Similarly, the younger the patient, the more likely postop inflammation will occur, 8,9 and these patients are at risk for capsular fibrosis and iritis postoperatively. From the surgical standpoint, the more balanced salt solution used, the greater the likeli- hood of postoperative inflammation. Longer surgical times also result in a higher likelihood of inflammation 1,6 Numerous comorbid condi- tions can directly impact the risk of increased postop inflammation 11,12 including diabetes or autoimmune disorders, or ocular conditions such as corneal disease, inflammato y conditions, glaucoma, weakened zonules/intraoperative floppy iris syndrome, history of retinal vascular disease, or a history of trauma, to name a few. Cystoid macular edema The incidence of post-cataract clinical CME is 1–2%, 2,13 but the incidence of angiographic CME is much higher. 12,13 In the short term, CME leads to patient discomfort and displeasure with their vision, but if the CME does not resolve, the visual detriment could be long lasting. There is increased cost of care, as these patients necessitate more chair time and prolonged drug use. Patient lifestyles are also chang- ing. Today's patients actively use computers, tablets, smartphones, and pay out-of-pocket for premium technologies (see Table 1). In short, these are not patients who tolerate any kind of disruption to their daily lifestyle well. As a result, anterior segment surgeons use anti-infla - matory medications prophylactically and during the postoperative period to diminish the likelihood of CME even further. 5,14,15