November 2007




NSAIDs … cold phaco and small incisions?

by Rich Daly EyeWorld Contributing Editor



Cataract surgery patient who recieved NSAIDs three days pre-op

Wide pupil dilation cataract patient who received a topical NSAID prior to surgery Source: Eric Donnenfeld, M.D.

Surgeons find increasing need for non-steroidal antibiotics with advanced surgical procedures and technology, including multifocal IOLs.

As advanced cataract technology and techniques, such as so-called cold phaco and small incision surgery, have become more common, surgeons report non-steroidal anti-inflammatory drugs (NSAIDs) have become more important.

Cold phacoemulsification and small incision cataract surgery require greater skill and are more technically demanding on the surgeon, said Jodi Luchs, M.D., assistant clinical professor of ophthalmology and visual sciences, Albert Einstein College of Medicine, Bronx, N.Y., and director, Department of Refractive Surgery and Cornea Service, Long Island Jewish/North Shore University Health System, Great, Neck, N.Y. “As a result, it is even more critical that the surgeon maximize patient comfort during the procedure with maximum topical analgesia and have a maximally dilated pupil which does not become miotic during the case,” Dr. Luchs noted. “Now, more than ever, perioperative NSAIDs play a crucial role in accomplishing these goals.”

Because these advanced techniques have allowed faster visual recovery following surgery patients have increasingly demanded better and faster visual recovery. Those expectations require surgeons to “maximize our patients protection” and protect them against the development of post operative macular thickening or cystoid macular edema (CME), he said. The best tools for achieving those surgical outcomes are the NSAIDs and steroid combination on which many surgeons have come to rely.

The newer approaches may have given surgeons more confidence in avoiding CME, said Eric D. Donnenfeld, M.D., co-chairman of cornea, Nassau University Medical Center, East Meadow, N.Y. Ophthalmic Consultants of Long Island, N.Y., however vision-impairing inflammation is still far more common than many suspect.

Research as recent as the September 2006 Journal of Cataract and Refractive Surgery CME study “Preoperative ketorolac tromethamine 0.4% in phacoemulsification outcomes: pharmacokinetic-response curve” found 12 % of cataract patients untreated with NSAIDs developed CME.

“All of these concerns have occurred despite the improvements in cataract surgery with cold phaco and smaller incisions,” Dr. Donnenfeld said, about the increased risk of CME post-op when NSAIDs are not used.

The CME risk has led Dr. Donnenfeld, , to increase his use of NSAIDs from immediately pre-op to three days pre-op and from two weeks post-op to one month post-op. The increased use after surgery aimed to counter a “rebound” of CME in his patients three to four weeks post-op.

Dr. Luchs said he has had the best results from Acular LS (ketorolac 0.4%, Allergan, Irvine, Calif.) dosing four times a day beginning three days before surgery, followed by Acular and Pred Forte (prednisone, Allergan) four times a day for one week post-op. He then tapers both drops by one dose each week.

Another newer technology that has necessitated an increased use of NSAIDs is multifocal IOLs. Dr. Donnenfeld’s research on Acular LS found that NSAIDs given at least three days pre-op significantly improved surgery outcomes, reduced intra-op time and improved quality of vision post-op.

“With multifocal IOLs you are walking a tightrope because there is an intrinsic loss of contrast sensitivity with the multifocal IOLs and any loss of contrast sensitivity associated with even mild subclinical CME reduces the quality of vision and contrast sensitivity in these patients, so that non-steroidals are absolutely imperative in all patients having multifocal IOL implantation.” He said.

Gaining favor over steroids?

Due to the “significant inflammation” Dr. Donnenfeld and other surgeons continue to find in uncomplicated cataract cases, many anticipate increased use of non-steroidal drugs. Although many surgeons have found NSAIDs safer than steroids, they also have much less potent anti-inflammatory effects than steroids. In recent years, some research has found that patients have good outcomes when steroids are eliminated and only NSAIDs are used. Because newer NSAIDs have shown increased effectiveness in this role, corticosteroids may become less important in preventing post-op complications.

Rosa Braga-Mele, M.D., M.Ed., associate professor, University of Toronto, Canada, and director of cataract unit and surgical teaching, Mt. Sinai Hospital, Toronto said she anticipates surgeons will continue to expand their use of NSAIDs and reduce their steroid use, especially for less traumatic procedures.

Use caution with NSAIDs

A contrarian view of NSAIDs was taken by Oliver D. Schein, M.D., M.P.H., Burton E. Grossman professor of ophthalmology, Johns Hopkins University, Baltimore, who does not support their routine use in cataract surgery because he has found clinically significant CME is rare. In addition, post-cataract surgery CME, when it does occur, responds well to NSAIDs, he noted. Use NSAIDs prophylactically, Dr. Schein said, only in patients who have experienced CME post-op in their first eye and in patients who have pre-existing diabetic macular edema.

Dr. Braga-Mele warns that surgeons should beware of using NSAIDs in patients with corneal surface disease, such as keratitis sicca and Sjogren’s syndrome “as they may run into corneal melt problems.” Currently she pairs NSAIDs with steroids in uncomplicated cataract procedures and in more complicated surgery or in patients with uveitis or trauma she relies on steroids to reduce inflammation and improve outcomes.

Surgeons should not use NSAIDs for extended periods of time in patients who have ocular surface disease, such as dry eye and exposure to keratits, Dr. Donnenfeld agreed. In such patients he cuts post-op use by half to two weeks.

Editors’ note: Dr. Luchs has financial interests with Allergan (Irvine, Calif.) and Inspire Pharmaceuticals (Durham, N.C.). Dr. Donnenfeld has financial interests with Alcon (Fort Worth, Texas) and Allergan. Dr. Braga-Mele has financial interests with Alcon.

Contact information
Braga-Mele: 416-462-0393,
Donnenfeld: 516-766-2519,
Luchs: 516-785-3900,
Schein: 410-955-8179,

NSAIDs … cold phaco and small incisions? NSAIDs … cold phaco and small incisions?
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