Eyeworld

EW FEATURE 118 Controversies in cataract surgery • April 2017 AT A GLANCE • Although NSAIDs may have some benefit for cataract surgery patients, surgeons remain divided on whether they are beneficial enough to prescribe along with topical corticosteroids. • Higher risk patients, such as those with diabetes, may be the best candidates for NSAID use before and after cataract surgery. • Due to lack of evidence, there is little agreement about ideal dosing regimens with NSAIDs. However, surgeons lean toward once-daily usage for better compliance, and some also favor branded topical NSAIDs over generics. Intracameral NSAIDs are now available in the U.S. • Risks from NSAIDs remain, but they are not common. by Vanessa Caceres EyeWorld Contributing Writer not effective enough or cost-effec- tive enough to replace or add to top- ical corticosteroid therapy. William G. Myers, MD, Chicago, said it is likely more cost-effective to increase the dosing of topical corticosteroids as needed rather than have patients use topical NSAIDs. High-risk and special patient populations In certain patient groups, the ben- efits of NSAID use associated with cataract surgery may not have an abundance of evidence, but sur- geons feel strongly that it could help cut the risk for CME. This includes patients with diabetes; in fact, the European Society for Cataract and Refractive Surgeons is leading a multicenter trial called PREMED (PREvention of Macular EDema after cataract surgery) to assess the better prophylactic regime for this group, Dr. Kessel said. Other patients considered high risk who may benefit from NSAIDs include those with previous retinal vein occlusions, those with epiret- inal membranes, and those with uveitis, Dr. Kessel said. And yet… "There is good evidence that NSAIDs should be used prophylactically after routine cataract surgery. I would recommend to use them in every pa- tient," said Line Kessel, MD, PhD, Glostrup Hospital, Department of Ophthalmology, Glostrup, Denmark. In Dr. Kessel's 2014 meta-analy- sis that focused on pseudophakic edema after cataract surgery, she and fellow researchers found that 25% of those who received steroids alone had edema as seen on fluorescein angiogram or OCT versus 4% in the NSAID-only group. 3 "There's a vast peer-review literature in Europe regarding the protection of the macula with nonsteroidals," said John Sheppard, MD, professor of ophthalmology, microbiology and molecular biology, and clinical director, Thomas R. Lee Center for Ocular Pharmacology, Eastern Virginia Medical School, Norfolk, Virginia. "I think there's no doubt that most American surgeons view them to be effective." Surgeons who do not routinely use NSAIDs in cataract patients say they can be effective—they are just that may translate in a short-term but not long-term improvement in vision in routine patients. The cost/ benefit analysis of NSAID use does not support their routine use," said Dr. Kim, who was the lead author of a 2015 review article on the topic of NSAIDs and cataract surgery. 1 His re- port found a lack of level 1 evidence that supports the long-term benefit of NSAID use to prevent vision loss from CME at 3 months postopera- tively. "Published studies have been limited by many factors, includ- ing small size, inadequate power; inconsistent protocols, such as topical NSAIDs plus corticosteroids compared to corticosteroids alone or NSAIDs compared to corticosteroids; variable duration of follow-up, lack of blinding, lack of a good internal control group, and potential bias from funding sources," said James P. Dunn, MD, director, Uveitis Unit, Wills Eye Hospital, Philadelphia. Dr. Dunn mentioned a recent Cochrane review that analyzed 34 studies with more than 5,000 patients that only found low-certainty evidence of a reduction in central retinal thickness or vision improvement. 2 Surgeons share differing views on NSAID effectiveness S urgeons fall divisively on different sides of the debate when they discuss the use of non-steroidal anti-inflammatory drugs (NSAIDs) for routine cataract sur- gery. Topical corticosteroid use in cat- aract surgery patients is the norm, although many surgeons feel that the addition of an NSAID can help reduce the chance of cystoid macu- lar edema (CME). Even though NSAIDs can have some benefits, there are also many surgeons who feel there's not enough of an advantage to prescribe them in all routine patients. "There is strong evidence that the benefit of routine NSAID use is small and the number of patients you'd have to treat to see any benefit is large," said Stephen J. Kim, MD, Department of Ophthalmology and Visual Sciences, Vanderbilt Universi- ty of Medicine, Nashville. "You have to treat nearly 300 people for one person to show a reduction in CME Weighing in on NSAID use during cataract surgery Cystoid macular edema 4 weeks after cataract surgery with 20/50 vision Source: Stephen J. Kim, MD

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