Eyeworld

EW CATARACT 40 August 2017 by Maxine Lipner EyeWorld Senior Contributing Writer ketorolac as his first-line agent because this tends to be inexpensive for patients. He starts these the week before surgery and continues them for as long as it takes to get the pa- tient "out of the woods." In certain cases, he will change the NSAID if he thinks it necessary. "There are no good studies comparing NSAIDs and their efficacy, but if I'm not getting the effect that I want with ketorolac, I'll usually bump it to something like Nevanac [nepafenac, Alcon, Fort Worth, Texas]," he said. "If I have a patient who is going to be on it for a long period of time, say they have an epiretinal membrane, I might bump them to Bromday [bromfenac, Bausch + Lomb] or some other once- a-day NSAID." This way they don't have to remember to put the drop in as often, and they won't have as much toxicity over a protracted period, he explained. Patients with compromised cor- neas are ones to be followed more closely with NSAIDs, Dr. Miller said. "Someone who has a sick cornea, a really dry eye, has had corneal melts or corneal ulcers, or has had a corne- al transplant, this is a patient whose cornea you're going to beat up with an NSAID," Dr. Miller said, adding that while he would still treat them, he would watch them more carefully and would stop the drug at the first sign of corneal problems. "That's where q.d. dosing is helpful," Dr. Miller said. "The cornea is going to get a little bit less irritated when you're dosing once a day versus three or four times a day." Dr. Miller also stressed the need to promptly start the medication. "The greatest benefit is to hit soon after surgery because you don't get as much benefit later on." Dr. Donaldson emphasized that preventing and treating CME is not the only reason to use NSAIDs these days. She cited a controversial paper that appeared in Ophthalmology by decrease CME after cataract surgery, although I strongly suspect that this is the case," Dr. Charles said. He uses NSAIDs in lieu of steroids in glau- coma steroid responders who are undergoing vitreoretinal surgery. For these cases, he prefers Ilevro. Kevin M. Miller, MD, Kolokotrones Chair in Ophthal- mology, David Geffen School of Medicine, University of California, Los Angeles, reserves NSAIDs for high-risk patients rather than using the shotgun approach of treating ev- eryone. "If you look at the literature, about 1% of non-selected individu- als will develop visually significant macular edema," Dr. Miller said, adding that with OCT evidence of macular edema, this only involves about 2% of the population. "If you're doing the shotgun approach, you're treating 98 of 100 people unnecessarily, with the cost, the cor- neal toxicity, and the aggravation," Dr. Miller said. "I would rather target the 2% if you can identify them so you can treat them prophylactically, or you can wait until they develop it and then treat them." Most of the literature on CME shows that this benefits those who have diabetes with vasculopathy. Other high-risk groups that may or may not get as much benefit include those who have epiretinal membranes, perhaps with a traction component to the vasculopathy, as well as patients who have had CME in their first eye. For the former pa- tients, it remains debatable whether the NSAIDs do much, but many treat these patients anyway, Dr. Mill- er said. As for the latter, Dr. Miller thinks it makes sense to prophylac- tically treat these patients as well. "Treat the ones who are at high risk prophylactically, and for the other 98%, wait until they develop it and treat them after the fact," he said. In cases where Dr. Miller does use NSAIDs, he opts for generic He favors Ilevro, citing its potency. In FDA clinical trials, 60% of those on Ilevro had no inflam- mation 2 weeks postop, whereas for most of the other NSAIDs this was at 40% and 20% for placebo. Kendall Donaldson, MD, as- sociate professor of ophthalmology, Bascom Palmer Eye Institute, Miami, starts her patients on NSAIDs 3 days before surgery and doses them for 1 month afterward. "I prefer the NSAIDs that are dosed daily such as Ilevro or Prolensa, but I generally use Ilevro because the insurance coverage is better in our region," she said. Dr. Donaldson uses the same approach for all of her cataract pa- tients. "I like to do things the same way in all of my cataract patients; that way, when my staff get calls, they have a standard response," she said, adding that she does watch the higher-risk patients more closely for development of epithelial toxicity or corneal melts, which, while rare, tend to occur in those with preex- isting ocular surface disease or other forms of inflammatory disease. While a month tends to be sufficient in most cases, if a patient has an epiretinal membrane preop- eratively that is retaining some fluid postoperatively, Dr. Donaldson may consider continuing the NSAID for longer. "We generally do an OCT at 1 month in those patients and reassess to see if we are going to con- tinue the NSAID treatment longer," she said. "A lot of times, the retinal specialist just wants to take the cataract out so that they can reassess and determine if further treatment may be warranted." Steve Charles, MD, clinical professor of ophthalmology, Uni- versity of Tennessee, Memphis, and founder of Charles Retina Institute, Memphis, often uses NSAIDs in his vitreoretinal surgery patients. "I do not have any science-based evidence that preoperative NSAIDs N SAIDs are part of many ophthalmic practitioners' regimens for at least some of their surgical cases. With several different NSAIDs available and varying ap- proaches to their use, EyeWorld took a look at how leading practitioners are using these to benefit patients. Uday Devgan, MD, chief of ophthalmology, Olive View–UCLA Medical Center, clinical professor, UCLA Jules Stein Eye Institute, and in private practice, Devgan Eye Sur- gery, Los Angeles and Beverly Hills, uses NSAIDs in all of his cataract surgeries. "I think there are a lot of surgeons like me who use NSAIDs for every single case," he said. "Oth- er surgeons use them selectively for some cases, and a few surgeons don't use them at all." Currently, there are several ma- jor NSAIDs in the U.S. These include Ilevro (nepafenac, Novartis, Basel, Switzerland), which is given once a day; Prolensa (bromfenac, Bausch + Lomb, Bridgewater, New Jersey), also given once a day; BromSite (brom- fenac, Sun Pharmaceutical, Mum- bai, India), dosed twice a day; and ketorolac, given four times a day. "Most people are using the once-a-day NSAIDs," Dr. Devgan said. Preoperatively, he likes to have the drug on board right when making the first incision. While Dr. Devgan finds it is sufficient to begin this just 1 day before cataract sur- gery, he asks patients to start 3 days before surgery, with practicality in mind. "Monday morning is my big OR day, and I do about 20 cataracts in a sitting," he said. "If I write the prescription for them to use it the day before surgery, many will wait until Sunday to go to the pharma- cy, and I'll get pharmacy calls on Sunday that they're out of it." He instead starts the patients on the medication 3 days before surgery so that his office can handle any issues that may arise on Friday. Postop, Dr. Devgan uses NSAIDs for 4 weeks, despite the FDA label- ing for 2 weeks. "We use NSAIDs for the off-label indication to prevent CME," he said. "CME may not pres- ent in the first 2 weeks, so we want to have the drug for the full 4 weeks to be sure to cover it." In some pa- tients who have preexisting under- lying issues, Dr. Devgan may keep them on the NSAID even longer. Update on NSAIDs Pharmaceutical focus Steve Charles, MD Uday Devgan, MD Kendall Donaldson, MD Kevin Miller, MD

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