Eyeworld

EW CATARACT 46 October 2016 by Ellen Stodola EyeWorld Senior Staff Writer are an absolute necessity. Considerations for glaucoma are included in the paper. Originally, this was only going to be an ASCRS paper, Dr. Hoffman said, but then the American Glaucoma Society got involved. There were several main points in the paper pertaining to glaucoma. The first is whether or not patients with glaucoma have a higher incidence of CME because of all the medications they are taking. A lot of these patients are on prosta- glandin agonists, Dr. Hoffman said, and it's been shown that they have slightly higher risk of CME because prostaglandins break down the vas- cular barrier. "These patients should be treated with a nonsteroidal at the time of cataract surgery, espe- cially if the prostaglandin cannot be stopped," he said. Patients who have glaucoma associated with pseudo- exfoliation have a higher incidence of small pupils and iris trauma from the surgery. This could potentially lead to a more complicated surgery, increased inflammation, and a high- er rate of CME, so they should be treated with nonsteroidals. NSAIDs have been used for nearly 30 years with success, the paper concluded. They have numer- ous uses in cataract surgery, both in complicated and routine cases. The paper is published in the September issue of JCRS. EW Reference Hoffman RS, et al. Cataract surgery and non- steroidal anti-inflammatory drugs. J Cataract Refract Surg. 2016;42(9):1368–1379. Editors' note: Dr. Hoffman has no financial interests related to his comments. Contact information Hoffman: rshoffman@finemd.com to discuss their use for CME, to talk about the different treatment para- digms in terms of whether physicians should be using them for all patients, and to review their potential adverse reactions. The concern was that there was a paper from a major organiza- tion saying that final visual acuity doesn't matter at 3 months, Dr. Hoffman said. "Surgeons have the option of using them or not but they've been shown to reduce the incidence of CME," he said. "Even if final visual acuities are no different at 3 months, patients who develop CME are distressed patients, so if you can avoid that, it's good." Patients who develop CME are not happy because they have impaired vision, he said. "If you tell them it will resolve in 2 to 3 months, some might be OK with it, but others might be angry and distrustful." Dr. Hoffman said the point of the paper was to give an overview of how nonsteroidals work, discuss what all the available ones and potencies are, and talk about their benefits. Nonsteroidals are used intra- operatively or right before surgery to keep the pupil dilated so that the cataract surgery goes routinely, Dr. Hoffman said. They help with pain control in surgery, and if used before surgery for a few days, there's a higher likelihood of preventing CME. These can also be used after surgery and can be used in place of steroids, especially for patients who can't take topical steroids, he added. This paper was a collaboration of more than a dozen surgeons, each with a different perspective, Dr. Hoffman said, and one or two did not use nonsteroidals routinely. Within the paper, it was stated that there are different ways to use non- steroidals. Some physicians don't use them at all, some just for high- risk patients, and some routinely in all patients, Dr. Hoffman said. Less than 2% and possibly less than 1% of cataract patients will develop CME. He stressed that the goal was for the paper to apply to everyone and to not imply that nonsteroidals Richard Hoffman, MD, Eugene, Oregon, discussed the paper and its importance. "Originally, this paper was a response to an article that was pub- lished in Ophthalmology by its retina committee," he said. The conclusion from that paper was that the visual acuity in patients with CME was no different at 3 months, which implied that physicians don't need to treat patients with nonsteroidals if they have CME. The concern surrounding this paper is that private insurance com- panies and Medicare might look at the conclusions and determine that coverage for NSAIDs at the time of cataract surgery is unnecessary. "This would make it harder for physicians to prescribe them to their patients," Dr. Hoffman said. Initially, this JCRS article was intended to be a white paper, Dr. Hoffman said, but it turned into a major review as a collaboration of the ASCRS Cataract Clinical Com- mittee and the American Glaucoma Society. The goal of the paper is to be comprehensive as a review of non- steroidal drugs for cataract surgery, to discuss the benefits of nonsteroidals, Literature review examines important considerations for nonsteroidal anti- inflammatory drugs in cataract surgery patients N onsteroidal anti-inflam- matory drugs (NSAIDs) help reduce pain and prevent complications in cataract surgery. They have benefits in a variety of patients when used alone or in combination with other treatment plans. A recent review, published in the Journal of Cataract and Refractive Surgery (JCRS), delves into preoperative, intraop- erative, and postoperative uses of NSAIDs, as well as mechanism of action, currently available NSAIDs, uses in certain cases, and special considerations for glaucoma pa- tients. The article reviews literature on available NSAIDs and use in cataract surgery. One important indication is for postoperative use in cataract surgery for treatment of cystoid macular edema (CME). There is also some evidence to support the use of preop NSAIDs in preventing CME. JCRS article reviews uses of NSAIDs

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