Q: The cataract patients Im comanaging are all being put on topical non-steroidal anti-inflammatory drugs (NSAIDs). Has the standard of care changed recently?
A: The standard of care for cataract surgery has not changed completely, but the use of NSAIDs is increasing, say the doctors interviewed for this article.
Cataract patients are still prescribed a topical antibiotic and a topical steroid perioperatively. But, until recently, only specific patients have been prescribed a topical NSAID to prevent cystoid macular edema (CME). This group includes patients with a history of uveitis, diabetes or retinal vascular conditions, as well as difficult surgery cases that involve more manipulation, says optometrist Jim Powers, who manages a secondary-care practice with a high proportion of cataract cases, in
CME is the most common cause of visual decline after uncomplicated cataract surgery.1 Its incidence has not changed, but knowledge about it has improved. After it occurs, CME is usually easily treated with topical NSAIDs or steroid injections, Dr. Powers says. This restores visual acuity, but contrast sensitivityan important consideration for patients with high-tech multifocal IOLsmay still be affected. So, in such patients, perioperative use of NSAIDs is a sensible option, Dr. Powers says.
Theres good reason for this trend, says eye surgeon Eric Donnenfeld, M.D., of
Topical NSAIDs inhibit prostaglandin synthesis, he says. Prostaglandins are largely responsible for intraoperative miosis and postoperative inflammation. So, treatment with a topical NSAID that blocks prostaglandin synthesis will help to maintain pupil size, reduce discomfort, and prevent CME.
Patients can appreciate this, too, says optometrist Dennis Mathews, of The Eye Specialty Group, in
The typical NSAID regimen to prevent CME is two or three days pre-op and up to one month post-op.2 None of the topical NSAIDs is specifically FDA-indicated for CME, and Dr. Mathews says that his practice has not noticed a significant difference between them. Still, distinctions among the four topical NSAIDs are worth noting:
Acular (ketorolac, Allergan) has the most research behind it, Dr. Donnenfeld says. It has been studied for post-cataract CME for more than 15 years.3
Xibrom (bromfenac, ISTA), Voltaren (diclofenac, Novartis) and Acular have been shown to be equally effective for treatment of post-cataract CME, though patients using Xibrom gained an average of 15 letters on the ETDRS chart compared with 11 letters for either Voltaren or Acular.4 Also, Xibrom is dosed b.i.d. while Voltaren and Acular are q.i.d., and Xibrom may sting less upon instillation.4
Nevanac showed greater and faster bioavailability than Acular LS or Xibrom (though Acular LS may better suppress prostaglandins).5 Also, Nevanac is dosed t.i.d.
Of course, prescribing an NSAID doesnt guarantee that a cataract patient wont get CME, Dr. Powers says.
1. Rossetti L, Autelitano A. Cystoid macular edema following cataract surgery. Curr Opin Ophthalmol 2000 Feb;11(1):65-72. Review.
2. Stephenson M. Targeting CME in routine cataract surgery. Rev Ophthalmol 2007 Sep;14(9):35-39,76.
3. Flach AJ, Stegman RC, Graham J, Kruger LP. Prophylaxis of aphakic cystoid macular edema without corticosteroids. A paired-comparison, placebo-controlled double-masked study. Ophthalmology 1990 Oct;97(10):1253-8.