Eyeworld

EW NEWS & OPINION 20 February 2016 by Michelle Dalton EyeWorld Contributing Writer the original studies themselves, including that they "overstate the effectiveness of NSAIDs because the studies are designed to maximize that effect." Most of the studies use the in- cidence of postop CME as a primary endpoint. "CME itself should not be a primary outcome," Dr. Kim said. As a majority of postop CME will resolve on its own, what these studies should parse out is the effect of NSAIDs on long-term visual func- tion and outcomes, he said. As part of the Ophthalmic Technology Assessment report by the American Academy of Ophthal- mology (AAO, San Francisco), Dr. Kim and colleagues conducted a literature search to evaluate the evi- dence on the efficacy of prophylactic topical NSAIDs used in preventing vision loss from CME and identified a potential 149 unique citations. 1 Of those, the group analyzed 12 cita- tions that met the inclusion criteria (sound methodological design with a sufficient number of patients to analyze the results). Although CME is a "good out- come to use," it's probably better as a secondary outcome, Dr. Kim said. Most studies will also compare a corticosteroid-only group to a corticosteroid-NSAID group without adjusting the corticosteroid dosing "so it is not a balanced comparison," Dr. Kim said. In the former group, dosing may be 4 times daily, but Several studies suggest that nonsteroidal anti- inflammatory agents may hasten visual recovery but have little long-term effect on outcomes A meticulous review of published clinical studies has suggested that non- steroidal anti-inflamma- tory drugs (NSAIDs) may hasten visual recovery after cataract surgery but have no effect on longer- term visual outcomes. Further, there is a "lack of level 1 evidence that supports the long-term benefit of NSAID therapy to prevent vision loss from cystoid macular edema (CME) at 3 months or more after cataract surgery," said Stephen Kim, MD, Vanderbilt University, Nashville, Tenn. More than 90% of cataract surgeons say they use a combination of NSAID in conjunction with a cor- ticosteroid on their cataract patients, "at a substantial cost to society and to the patient," he said, "but there really has not been definitive evidence that there is a long-term benefit to this practice." The literature can be equally confusing, he said. The published meta-analyses do not consider what Dr. Kim labels as issues with No real proof NSAIDs are advantageous for CME prophylaxis " Right now, there's no established benefit to using an NSAID. I would hold off on recommending them until there's actual evidence that it makes a difference. " –Stephen Kim, MD in the latter combination group, patients are instilling up to 8 drops daily. These studies have "consistently demonstrated" a therapeutic effect when corticosteroids and NSAIDs are used in conjunction, but "this can be explained by an additive effect of 2 anti-inflammatory drugs," the report says. But that's not to say physicians should completely abandon their current treatments regimens. Physi- cian preference will continue to be best for now, Dr. Kim said. "Right now, there's no estab- lished benefit to using an NSAID," he said. "I would hold off on recom- mending them until there's actual evidence that it makes a difference." Dr. Kim does not use NSAIDs in the postop cataract period, but will use corticosteroids, typically 72 hours before surgery and up to 4–6 weeks after. "You have to let patients know the $200 NSAIDs are going to speed up their visual recovery, but won't make a difference in the long run," Dr. Kim said. NSAID use in the diabetic population There is some support for NSAID use in a cataract-diabetic population as prophylaxis, but it's far from a unan- imous opinion, experts say. Topical NSAIDs "significantly reduced the odds of developing CME, as compared to topical cortico- steroids, in non-diabetic and mixed populations," according to one me- ta-analysis. 2 But the same meta-anal- ysis found a combination of topical NSAIDs and corticosteroids reduced OCT of an eye with CME after phacoemulsification (left) and after treatment with NSAID and prednisolone (right) Source: Neal Shorstein, MD

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