Eyeworld

New vehicles New anti-inflammatory vehi- cles offer decreased toxicity, increased solubility, increased ocular concentrations, and easi- er dosing. Some medications have added guar gum, which acts as a stabilizer and thickening agent (e.g., nepafenac 0.3%). Muco- adhesive technology adheres to the ocular surface and has adaptive viscosity (e.g., lotepre- dnol gel 0.5%). Lipid-emulsion technology increases the bio- availability of the drug (e.g., difluprednate 0.05%). The future trend will be to instill medications during surgery. An injectable, preserva- tive-free, bisulfate-free form of phenylephrine 1% and ketorolac 0.3% is added to the irrigating solution, maintaining pupillary dilation and reducing pain. Compounding pharmacies provide proprietary antibiotic and steroid formulations for single injectable intraocular doses, allowing surgeons to load the eye with medication and reduce the need for postopera- tive drops. As well as treating inflamma- tion, NSAIDs are indicated for pain control. In separate clinical studies, pain-free days have been reported with both bromfenac and nepafenac. Use of brom- fenac 0.07% demonstrated a statistically significant percent- age of subjects with ocular pain scores of grade zero compared with placebo. 8 Nepafenac 0.3% and 0.1% had more pain-free days, which was statistically significant, compared with the vehicle arms. 9 When weighing branded medications versus generics, we need to remember that branded drugs pass a rigorous approval process, but generics have an ab- breviated process. Furthermore, the vehicles and formulations are not the same. In a multicenter study, patients having bilateral phacoemulsification received pulsed initial doses of diflupred- nate 0.05% in 1 eye and pred- nisolone acetate 1% in the other immediately before and after surgery. 1 On postoperative day 1, 62% of eyes receiving diflupred- nate vs. 38% of those receiving prednisolone were free of corne- al edema as defined by pachym- etry. Those receiving diflupred- nate also had better visual acuity on day 1, less retinal edema at day 15, and greater endothelial cell density at day 30. The incidence of postoper- ative CME is considered to be up to 6% of cataract patients as identified by fluorescein angiog- raphy and visual acuity; howev- er, optical coherence tomogra- phy has shown an incidence of 9% to 19%. 2,3 It is important to proactively prevent CME; treatment does not have the same outcome as prevention. Topical nonsteroidal anti- in- flammatory drugs (NSAIDs) and corticosteroids work synergisti- cally to reduce inflammation, and they have their own advan- tages and disadvantages. Surgeons in Europe use nepafenac 0.1% to prevent CME. This use is off-label in the Unit- ed States, where NSAIDs are ap- proved to control inflammation and reduce postoperative pain. We know NSAIDs prevent CME more effectively than cor- ticosteroids. 4 In patients at high risk of CME (e.g., patients with diabetes or a history of inflam- mation or CME), NSAIDs are used as long as 90 days, as well as preoperative loading of the cornea. NSAIDs are safe in most pa- tients; the vast majority of cor- neal melts with NSAIDs occurred in patients with dry eye and those using generic NSAIDs. 5–7 Dr. Holland's perioperative inflammation regimen Preoperatively: • Pretreat with nepafenac 0.3% QD—routine cases: 1 day preoperatively; high-risk cases: 7 days preoperatively • Topical moxifloxacin 0.5%, nepafenac 0.3%, and difluprednate 0.05% day of surger y Intraoperatively: • Phenylephrine 1%/ketorolac 0.3% injection (in balanced salt solution) Postoperatively: • Topical moxifloxacin 0.5% BID for 1 week • Topical difluprednate 0.05% BID for 2 weeks and QD for 1 week • Topical nepafenac 0.3% QD—routine cases: 4 weeks; high-risk cases: 8 weeks continued from page 3 Conclusion Controlling inflammation is essential to achieve optimal outcomes and reduce the risk of complications after cataract sur- gery. Surgeons need to make the most of available technology to reduce the risk of inflammation. References 1. Donnenfeld ED, et al. A multicenter ran- domized controlled fellow eye trial of pulse- dosed difluprednate 0.05% versus prednis- olone acetate 1% in cataract surgery. Am J Ophthalmol. 2011;152:609–617. 2. Perente I, et al. Evaluation of macular changes after uncomplicated phacoemul- sification surgery by optical coherence tomography. Curr Eye Res. 2007;32:241– 247. 3. Eriksson U, et al. Macular edema and visual outcome following cataract surgery in patients with diabetic retinopathy and controls. Graefes Arch Clin Exp Ophthalmol. 2011;249:349–359. 4. Kessel L, et al. Post-cataract prevention of inflammation and macular edema by ste- roid and nonsteroidal anti-inflammatory eye drops: a systematic review. Ophthalmology. 2014;121:1915–1924. 5. Singh R, et al. Evaluation of nepafenac in prevention of macular edema follow- ing cataract surgery in patients with diabetic retinopathy. Clin Ophthalmol. 2012;6:1259–1269. 6. Carreno E, et al. Update on twice-daily bromfenac sodium sesquihydrate to treat postoperative ocular inflammation following cataract extraction. Clin Oph- thalmol. 2012;6:637–644. 7. O'Brien TP. Emerging guidelines for use of NSAID therapy to optimize cata- ract surgery patient care. Curr Med Res Opin. 2005;21:1131–1137. 8. Walters TR, et al. Bromfenac ophthal- mic solution 0.07% dosed once daily for cataract surgery: results of 2 random- ized controlled trials. Ophthalmology. 2014;121:25–33. 9. Modi SS, et al. Once-daily nepafenac ophthalmic suspension 0.3% to prevent and treat ocular inflammation and pain after cataract surgery: phase 3 study. J Cataract Refract Surg. 2014;40:203–211. Dr. Holland is director of the cornea service, Cincinnati Eye Institute, and professor of clinical ophthalmology, University of Cincinnati, Ohio. He can be con- tacted at eholland@holprovision. com. Advanced therapeutic and surgical options to eliminate post-cataract surgery inflammation and pain 4

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