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January 2012 Retina co-morbidity for the anterior segment surgeon February 2011 EW FEATURE 45 non-generics, I think generic NSAIDs might be considered, out of respect to our patients' financial health," he said. He also believes that optimal An epiretinal membrane, which makes it highly likely that the patient will have CME after routine cataract surgery Source: Uday Devgan, M.D. NSAIDs if the patient is at a higher risk for CME, with risk factors in- cluding epiretinal membrane, dia- betes mellitus, cataract surgery complicated by vitreous loss, or a history of post-op macular edema after cataract surgery in the con- tralateral eye. "In these settings, I routinely use an NSAID such as bromfenac [Bromday, Ista Pharmaceuticals, Irvine, Calif.], nepafenac [Nevanac, Alcon, Fort Worth, Texas], or ketoro- lac [Acular, Allergan, Irvine, Calif.]. I continue the NSAID until topical steroids have been discontinued," he said. Patients typically use these medications for 1-3 months, he said. Dr. Verdier emphasized his pref- erence for generic NSAID use. "Un- less there is compelling evidence of an advantage of more expensive Poll Size: 397 dosing for NSAIDs, in his hands, dif- fers from what manufacturers rec- ommend. For example, he uses nepafenac twice a day instead of three times a day and ketorolac two times a day instead of four times a day. Treating acute CME When acute CME occurs post-opera- tively, Dr. Devgan checks to make sure that other anatomical defects, such as vitreous behind the lens, are not occurring. If he does not find anything, he uses topical NSAIDs for treatment and follows the patient with the use of ocular coherence to- mography on a week-to-week basis. He usually finds some improvement within 1-2 weeks of the peak inci- dence, but treatment with medica- tions will continue for several weeks. Dr. Devgan prescribes NSAIDs such as Bromday, Acular, and Nevanac, and sometimes genetic choices. He also uses a topical steroid such as prednisolone acetate 1% (Pred Forte, Allergan) or Durezol (difluprednate ophthalmic suspen- sion 0.05%, Alcon) if NSAIDs do not seem to improve the eye. Dr. Verdier's treatment course for acute CME is very similar, adding that he will follow the treatment course and then taper over 1-3 months. "If [the patient] is recalci- trant to this treatment, I readily refer to a retinal specialist," he said. Another CME treatment option is Diamox (acetazolamide, Duramed, Cincinnati), Dr. Devgan said. "Di- amox as a pill lowers pressure in the skull and lowers IOP, and it may help with macular edema," Dr. Devgan said. Dr. Warren also treats CME with NSAIDs three times a day for 6 weeks and periocular steroids such as Durezol. He will administer a sub- Tenon's injection of triamcinolone 4 mg and discontinue the topical steroid but continue the NSAID for another 6 weeks if necessary. "Generally at about 6 weeks, I see improvement," he said. A push for effective topical treatment over injections is a crucial issue right now in CME, Dr. Warren said. "It's easier to do, and everyone likes it better," he said. Treating chronic CME Chronic CME, which can occur 3-6 months after surgery, can be chal- lenging to treat if it's caused by an anatomical defect that was not fixed, Dr. Devgan said. "The longer CME is there, the worse the progno- sis is," he said. "It's hard for the pa- tient to understand what is happening." Certain patients have a greater risk for chronic CME, such as those with diabetic retinopathy, uveitis, or a history of CME in the other eye, Dr. Warren said. Dr. Warren reported in a 2010 study published in Retina a more ag- gressive treatment for chronic CME, involving intravitreal triamcinolone and an injection of bevacizumab (Avastin, Genentech, South San Francisco). The 39 patients in the study were randomized to receive one of four topical NSAIDs or a placebo for 4 months. At weeks 12 and 16, patients who received NSAIDs, particularly nepafenac and bromfenac, had a significant reduc- tion in retinal thickness compared with those who received the placebo. EW Editors' note: Dr. Devgan has financial interests with Alcon, Ista Pharmaceuti- cals, and Bausch + Lomb (Rochester, N.Y.). Dr. Warren has financial inter- ests with Alcon, Dutch Ophthalmic Research Center (Zuidland, the Nether- lands), and Genentech. Dr. Verdier has no financial interests related to this article. Contact information Devgan: 800-337-1969, devgan@gmail.com Verdier: 616-949-2001, daverdier@aol.com Warren: kwarren@warrenretina.com EyeWorld Monthly Pulse EyeWorld Monthly Pulse is a reader survey on trends and patterns for the practicing ophthalmologist. Each month we send a 4-6 question online survey covering different topics so our readers can see how they compare to our survey. If you would like to join the current 1,000+ physicians who take a minute a month to share their views, please send us an email and we will add your name. Email ksalerni@eyeworld.org and put EW Pulse in the subject line; that's all it takes. Copyright EyeWorld 2011