February 2019

CATARACT

Pharmaceutical focus
Eyes on NSAIDs for cataract surgery


by Maxine Lipner EyeWorld Senior Contributing Writer






Pupillary miosis associated with femtosecond laser-assisted cataract surgery can be limited through preoperative treatment with topical NSAIDs.
Source: Kendall Donaldson, MD

Surgeons share how they use NSAIDs

When it comes to NSAIDs, most people in the U.S. use them in cataract cases, said Kendall Donaldson, MD, Bascom Palmer Eye Institute, Plantation, Florida. “However, there are some surgeons who have gotten away from drops entirely and are doing various forms of injections. However, the majority are still using drops including a nonsteroidal,” Dr. Donaldson said.
She noted there are three main reasons for using an NSAID in such cases: pain control, improved dilation, and reduced risk of cystoid macular edema (CME). “Certainly, if you have a diabetic patient who has poor pupillary dilation and a complex cataract, they’re at higher risk for macular edema,” Dr. Donaldson said.
Dr. Donaldson’s own regimen is to use NSAIDs for all of her cataract patients. “My preferred prescribing regimen is to use branded drops instead of the generics because I can use those less frequently,” she said. “Generally, I use Ilevro [nepafenac, Novartis, Basel, Switzerland], and I can do that one time a day.” Dr. Donaldson starts the NSAID 3 days before surgery, mostly to help with pupillary dilation, and continues patients on this for 1 month postop.
In some cases, she might keep patients on the regimen longer if they have preexisting macular edema in that eye or CME in the other eye. The exception would be if there was something unique about the first eye such as a trauma, she noted.
She does not use the intraoperative NSAID Omidria (phenylephrine/ketorolac, Omeros, Seattle), since her hospital-based practice has not yet allowed surgeons to obtain it for financial reasons. If given the opportunity, she said she would use it since it has been shown to help pupils remain dilated as well as improve comfort during the surgery and in the early postoperative period.
Deepinder K. Dhaliwal, MD, University of Pittsburgh School of Medicine, prescribes NSAIDs for all of her cataract patients. She finds the newer NSAIDs preferable but knows that these are sometimes cost prohibitive. Her preference is for agents such as bromfenac (BromSite, Sun Pharmaceutical, Mumbai, India) and nepafenac because the frequency of instillation is less and the molecules penetrate better inside the eye. While this makes it easier for the patient, if it is not affordable, she will instead prescribe the generic NSAID ketorolac.
Dr. Dhaliwal’s regimen varies depending on the patient. In a high-risk patient with a CME issue or an epiretinal membrane, she starts them on the NSAID 1 week ahead of time. Meanwhile, for routine patients, she begins the medication just 1 hour ahead of time.
Postoperatively, Dr. Dhaliwal holds off on prescribing the NSAID. “For the first week postop, I do not use an NSAID. I just use a steroid because they’re on enough drops and I want to make sure that any epithelial defect is healed,” she said. “I don’t want to bombard their epithelial surface with anything that could delay restoration of a smooth ocular surface. There have been several reports of corneal melting when NSAIDS are used in compromised corneas.”
Dr. Dhaliwal sees patients at the 1-week postoperative mark to make sure that they are doing well. If they are, she adds the NSAID and recommends that a routine patient use this until the bottle is empty and a high-risk patient continue to use this for 8 weeks. However, if someone has a compromised cornea with a persistent epithelial defect, Dr. Dhaliwal will forgo the NSAID entirely.
Richard Stiverson, MD, Denver, takes what he terms a selective approach to NSAID use, reserving this only for those at high risk for CME. The incidence of CME after uncomplicated cataract surgery in a patient who has no risk factors is just 1%, he pointed out. “Of that 1 in 100 who have CME with uncomplicated surgery and no risk factors 80% of those patients’ CME will resolve on its own with no treatment at all,” he said. He thinks those who give all patients an NSAID may be unnecessarily treating 99 out of 100 patients who have cataract surgery. With some of the NSAIDs costing well over $100 per bottle, this can result in a hefty cost burden.
“I use it any time that I’ve had a surgery where there’s a complication and for refractive cataract surgery,” Dr. Stiverson said. “They’re paying extra money out of pocket for a refractive outcome, for as good vision as possible without glasses.” Also, if someone has had a capsule rupture, iris trauma, or if the surgery took longer than expected, he puts the patient on an NSAID, as well as anyone with diabetic retinopathy within the macular region, uveitis, CME in the fellow eye, or other high-risk patients.
In such cases, Dr. Stiverson noted that practitioners use either ketorolac or diclofenac. “When we use it, it’s always QID dosing,” he said. “We start the day before surgery and continue it for 1 month after.” If someone does get CME, Dr. Stiverson typically treats them for a minimum of 3 months until it’s completely resolved.
There’s no evidence that any other type of NSAIDs is any more effective, he stressed, adding that while bromfenac seems to be more potent, there are no good studies indicating that it’s more effective. “But I think the twice a day dosing is appealing,” Dr. Stiverson said. “If and when that becomes generic, I think we would use that at Kaiser.”
Kevin M. Miller, MD, David Geffen School of Medicine, University of California, Los Angeles, reserves NSAIDs for those at high risk for CME, also citing the lack of cost effectiveness with what he calls the shotgun approach. “For me, the cost effectiveness isn’t there doing that approach,” he said, adding that with the selective use approach, you limit the cost and toxicity to those patients most likely to benefit.
For this he tends to prescribe ketorolac four times a day and assesses the patient again at 2 weeks postoperatively. “We do our final refraction at that point. If they’re not at 20/20 acuity, we’ll do an OCT,” he said. “If they don’t develop the disease, they’re off the drops by 4 weeks out.” As for pretreatment, he usually begins the NSAID 1 week before. “But for the majority, I don’t pretreat,” he said.
Femtosecond laser-assisted cataract surgery is another matter. Dr. Miller finds without the NSAID a patient may be well dilated, but once the femtosecond laser is used, the pupil comes down and you can’t get it back to the same size. “There’s plenty of literature that says instilling an NSAID before the femtosecond laser will help reduce the post-treatment miosis,” Dr. Miller said. “For my femtosecond patients, which constitutes 80–85% of my practice, they get one drop of an NSAID 30 minutes before surgery and that’s it. They’re not put on NSAIDs for long-term use.”

Editors’ note: Dr. Donaldson has financial interests with Alcon (Fort Worth, Texas), Allergan (Dublin, Ireland), Bausch + Lomb (Bridgewater, New Jersey), and Johnson & Johnson Vision (Santa Ana, California). Dr. Miller has financial interests with Alcon, Johnson & Johnson Vision, and Carl Zeiss Meditec (Jena, Germany). Dr. Dhaliwal and Dr. Stiverson have no financial interests related to their comments.

Contact information

Dhaliwal
: dhaliwaldk@upmc.edu
Donaldson: KDonaldson@med.miami.edu
Miller: kmiller@ucla.edu
Stiverson: rk.53stiverson@gmail.com

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