EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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52 EW CATARACT Talking continued from page 50 same molecule that we've been using for more than a decade." He pointed out that what has essen- tially changed is that the carrier is thicker and more viscous and stays around the eye longer. Dr. Devgan also noted that it is important to understand that different molecules require different concentrations to achieve the same effect. "While Acuvail is 0.45% ketorolac, Nevanac is 0.1% nepafanac, and Bromday is 0.09% bromfenac, so out of the bottle the concentration of drug is five times higher in Acuvail com- pared to Bromday," he said. If you draw samples from the anterior chamber you would expect to see differences in concentrations, but that doesn't necessarily correlate with binding to the COX receptors to inhibit inflammation. He "test drives" all of the med- ications to decide which he prefers for his patients. Clinically speaking he finds that one of the advantages of Bromday is the dosing schedule. "Once a day is obviously convenient for patients, especially if they have as use NSAIDs for many weeks," Dr. Devgan said. He pointed out that Bromday is halogenated with a polarizing molecule added to it. "That allows the molecule to pene- trate the eye better and to bind more strongly to the receptor," he said. Dr. Devgan sees nepafenac as another solid NSAID option. "Nepafenac is a molecule that works well," he said. "It also has the bene- fit of being extra thick and viscous so it stays on the ocular surface." One down side is that it currently has to be dosed three times a day. However, he pointed out that there will likely be a new version soon. Overall, Dr. Bucci sees the changes that Acular has undergone to turn it into the current Acuvail as clinically beneficial ones. "What we did learn about the next generation of ketorolac molecule, Acuvail, is that it still absorbs well and more than the two major competitors," he said. "I think it's doing its job in the eye because of what it is as a molecule and how much of it has penetrated into the aqueous." Meanwhile, Dr. Devgan pointed out that as long as practitioners include an NSAID in their cataract regimen, they can't lose. It's the idea of not using one altogether post-op that could be detrimental. "It's im- portant to remember that the visual results that the patient achieves are half dependent on my surgical tech- nique and how elegantly the surgery was performed and half dependent upon the post-operative healing and inflammation control," he said. "Even if you're a brilliant surgeon, you'd better make sure that you have an appropriate post-operative regimen for your patients so that they achieve the maximum visual benefits." EW References Bucci FA Jr, Waterbury LD. A randomized comparison of to-aqueous penetration of ketorolac 0.45%, bromfenac 0.09% and nepafenac 0.1% in cataract patients undergoing phacoemulsification. Curr Med Res Opin. 2011 Dec;27(12):2235-9. Bucci FA Jr, Waterbury LD. Prostaglandin E2 inhibition of ketorolac 0.45%, bromfenac 0.09%, and nepafenac 0.1% in patients undergoing phacoemulsification. Adv Ther. 2011 Dec;28(12):1089-95. Editors' note: Dr. Bucci has financial interests with Allergan, Abbott Medical Optics (Santa Ana, Calif.), Bausch + Lomb (Rochester, N.Y.), Hoya Surgical Optics (Chino Hills, Calif.), and ISTA. Dr. Devgan has financial interests with Alcon and ISTA. Contact information Bucci: buccivision@aol.com Devgan: 310-388-3028, Devgan@gmail.com October 2012