Eyeworld

58 The X Factors: Three areas that will improve refractive cataract surgery outcomes Strategies continued from page 56 we can treat with NSAIDs and ste- roids for a synergistic effect. Rap- idly reducing inflammation keeps patients comfortable and optimizes visual recovery. Manufacturers have developed advanced anti-inflammatory formu- lations, taking existing active phar- maceutical ingredients and enhanc- ing the vehicles to improve efficacy. They are safer for the ocular surface and available in different concentra- tions. Our goal is to enhance efficacy through increased penetration and tissue concentrations. Newer formu- lations decrease dosing, which may improve patient compliance. Bromfenac, diclofenac, ketoro- lac, and nepafenac are the most common topical NSAIDs. Topical corticosteroids include dexameth- asone, difluprednate, loteprednol etabonate gel, and prednisolone acetate. Vehicles in generic vs. brand name medications vary. Generic drops differ significantly in drop volume, viscosity, surface tension, and bottle tip. 1 Pain is a continuum, however, Fung et al. reported that any postop- erative pain significantly predicted patient dissatisfaction with care. 2 NSAIDs effectively reduce post- operative pain (Figure 1). In a phase 3 trial, postoperative pain improved significantly in those receiving a new injectable formulation, phen- ylephrine 1% and ketorolac 0.3% injection vs. placebo. 3 We also have compounded formulations of steroids and antibi- otics that can be administered via a transzonular approach. Although clinically significant CME ranges up to 6%, optical co- herence tomography (OCT) imag- ing shows CME in up to 19% after cataract surgery. If a cataract patient with 20/20 vision complains of decreased visual acuity, we use OCT to check for CME. CME may reduce visual quality without reducing visual acuity. There are many ways to max- imize penetration of these agents, including prodrug technology, emul- sion technology, increased residual time on the ocular surface, subcon- junctival injection, intracameral or intravitreal injection into the eye, and increased dosing frequency. For my patients, I prescribe an NSAID starting one day preop- eratively. On the day of surgery, patients receive an NSAID before surgery; they receive a drop of difluprednate at the end of the case and one in recovery, as well as epi-Shugarcaine. My postoperative regimen is one drop of diflupred- nate each morning and one drop of nepafenac ophthalmic suspension before bedtime each day. Because pa- tients dislike eye drops, this regimen with new formulations results in happy patients (Figure 2). Conclusion All cataract patients require a quiet eye for the best visual results. Newer anti-inflammatories with enhanced drug delivery vehicles have improved concentrations while decreasing toxicity. Although CME is rare, it can be very serious, and NSAIDs and steroids are very helpful in preventing it. References 1. Cantor LB. Ophthalmic generic drug approval process: implications for efficacy and safety. J Glaucoma. 1997;6:344–349. 2. 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;100:1644–1650. 3. Lindstrom RL, Loden JC, Walters TR, et al. Intracameral phenylephrine and ketoro- lac injection (OMS302) for maintenance of intraoperative pupil diameter and reduction of postoperative pain in intraocular lens replacement with phacoemulsification. Clin Ophthalmol. 2014;8:1735–1744. Dr. Goldman is founder of Goldman Eye, Palm Beach Gardens, Fla. He can be contacted at david@goldmaneye. com. " Rapidly reducing inflammation keeps patients comfortable and optimizes visual recovery. " vs. ultrasound. The cavitation diam- eter is much smaller, resulting in up to 1,000 times less collateral damage. Reducing inflammation results in faster visual recovery. In addition, decreased ultrasound energy is par- ticularly important in patients with shallow anterior chambers, Marfan's syndrome, pseudoexfoliation or zonular dehiscence, and corneal disease. All of the available femtosecond laser platforms have shown strong reductions in EPT and energy. We are developing more instrumentation to complement FLACS. Based on my experience, any substantial reduction in phaco energy is highly beneficial (Figure 2). Although zero phaco is an excellent goal, minimizing phaco is a huge improvement. However, we need to avoid running huge volumes of fluid through the eye in our effort to minimize phaco. Side effects from the femto- second laser such as gas bubbles or increased intraocular pressure or temperature have not increased the risk of macular edema. 1 Reduced inflammation Data from a 25-center international study 2 examined the performance of standard coaxial phacoemulsifica- tion, coaxial microincision cataract " Advances in phacoemulsification technology and surgical techniques are reducing surgical stress. " surgery (C-MICS), and bimanual (biaxial) microincision cataract surgery (B-MICS). The EPT was 4.6 seconds in the 811 C-MICS cases. In comparison, in my 470 femtosecond cases performed with microburst phacoemulsification, my average EPT was 1.1 seconds. Many reports in the literature show that FLACS reduces corneal swelling because there is less trauma to the endothelial cells. There is typically less macular edema because there's less inflammation. 3 A recent study by Schultz et al. showed that prostaglandins increase instantly after femtosecond laser treatment. 4 Using preoperative non- steroidals or intraoperative nonste- roidals such as phenylephrine 1% and ketorolac 0.3% injection helps reduce prostaglandin release and keeps pupils from shrinking, reduc- ing postoperative inflammation. Conclusion Reduced ultrasound energy leads to a reduction in corneal edema, endo- thelial cell loss, and—most import- ant—postoperative inflammation. Decreased inflammation trans- lates into improved vision and more rapid visual recovery. References 1. Conrad-Hengerer I, Hengerer FH, Al Juburi M, Schultz T, Dick HB. Femtosecond laser-in- duced macular changes and anterior segment inflammation in cataract surgery. J Refract Surg. 2014;30:222–226. 2. Study on Stellaris Vision Enhancement System, Bausch + Lomb, data on file. 3. Nagy ZZ, Ecsedy M, Kovács I, et al. Macular morphology assessed by optical coherence tomography image segmentation after femto- second laser-assisted and standard cataract surgery. J Cataract Refract Surg. 2012; 38:941–946. 4. Schultz T, Joachim SC, Kuehn M, Dick HB. Changes in prostaglandin levels in patients undergoing femtosecond laser-assisted cataract surgery. J Refract Surg. 2013; 29:742–747. Dr. Jackson is founder and CEO of Jacksoneye, Lake Villa, Ill. He can be contacted at mjlaserdoc@msn.com. Impact continued from page 57

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