October 2020

CATARACT

Research Highlight
Use of NSAIDs and corticosteroids to stave off CME


by Maxine Lipner Contributing Writer

While physicians agree that prevention of CME after cataract surgery is important, how to prevent it can be a point of contention. The idea of using an NSAID alone received a boost from a recent study, with results indicating that bromfenac had lower CME rates than three other regimens.1
The retrospective review included four different regimens from surgeons at Wake Forest University. For three of these regimens, different combinations of generic and brand name NSAIDs and steroids were used, said Keith Walter, MD, adding that the fourth involved use of the bromfenac alone. This regimen had a CME rate of 0.09% vs. the overall rate of 0.82%, Dr. Walter reported.
Dr. Walter said he has relied on an NSAID-only approach since 2009. He often found himself having to write an extra prescription for the nonsteroidal after he stopped receiving it in a free sample kit he had been offering patients. “I thought bromfenac in particular is a good NSAID, which at that time was just twice a day,” he said. This dosing schedule was more enticing than asking patients to take drops 4–6 times a day with a complicated tapering schedule, he said.
However, not all NSAIDs are the same, he stressed. The generic ketorolac, for example, needs to be taken 4 times a day, which can be difficult for patients to comply with for more than a couple of weeks since this can lead to dryness as well as some toxicity issues.
Dr. Walter only adds a steroid in those rare cases where patients have a lot of symptomatic cell and flare. “If you have some retained cortex or retained lens fragment, you might see extra inflammation for that reason,” he said.
While there is some literature that shows a benefit to using both agents, often studies don’t include an arm showing the effect of using an NSAID alone, Dr. Walter said. He views the European PREMED study, which looked at bromfenac vs. a steroid, as poorly designed because bromfenac was only administered for 2 weeks postoperatively.2 This is not adequate for the prevention of CME, which usually spikes around 4 weeks postoperatively, Dr. Walter said.

Combination considerations

William Trattler, MD, however, thinks that both an NSAID and steroid are helpful for cataract patients. “I find that corneal swelling after cataract surgery is quite frustrating for patients who expect rapid visual recovery. Topical steroids help prevent and treat corneal edema. Topical NSAIDs are critical, too, as they help keep the pupil large during cataract surgery, reduce intraoperative and postop pain, and help prevent CME. So including both a steroid and NSAID in and around cataract surgery provides faster visual recovery and a better intraoperative and postoperative experience for patients,” Dr. Trattler said. He starts both agents 3 days preop.
In his view, an NSAID alone is insufficient, and it would also be a mistake to use only a steroid with cataract surgery. “If you only use steroids, then you’re going to be in real trouble as far as CME,” Dr. Trattler said. He cited the Wittpenn study, which showed that when patients were randomized to receive either a steroid plus an NSAID or steroid alone, those that received the combination had less swelling of the macula on OCT.3 “Since then, many have confirmed that these topical NSAIDs are synergistic with steroids,” Dr. Trattler said.

Steroid alone

Kevin M. Miller, MD, uses an antibiotic and prednisolone alone for standard cataract surgery. He views nonsteroidal agents as having a benefit to a small subsection of the population. “There are all kinds of costs and toxicity associated with nonsteroidals,” Dr. Miller said, adding that he reserves the NSAIDs for high-risk patients, such as those with retinitis pigmentosa or diabetic macular edema. “If you look at the literature, it’s 1–2% of routine uncomplicated cataract surgery patients who suffer from postoperative macular edema,” he said. “If you treat everyone with a nonsteroidal, you will treat 100 people for the sake of one or two.”
If Dr. Miller finds patients do have CME, he puts them on a regimen of an NSAID and prednisolone, both 4 times a day until the edema is gone. “We usually taper them off the nonsteroidal first because it’s irritating, then we’ll taper them off the steroid,” he said.
Currently, deciding the best approach means weighing all of these considerations and deciding which best suits a given patient. The doctors here stressed that performing the cleanest surgery possible can get patients off to a promising start.

About the doctors

Kevin M. Miller, MD
Kolokotrones Chair in Ophthalmology
David Geffen School of Medicine at UCLA
Los Angeles, California

William Trattler, MD
Director of Cornea
Center for Excellence in Eye Care
Miami, Florida

Keith Walter, MD
Professor of Ophthalmology
Wake Forest University
Winston-Salem, North Carolina

References

1. Walter KA, et al. Incidence of cystoid macular edema following routine cataract surgery using NSAIDs alone or with corticosteroids. Arg Bras Oftalmol. 2020;83:55–61.
2. Wielders LPH, et al. European multicenter trial of the prevention of cystoid macular edema after cataract surgery in nondiabetics: ESCRS PREMED study report 1. J Cataract Refract Surg. 2018;44:429–439.
3. Wittpenn JR, et al. A randomized, masked comparison of topical ketorolac 0.4% plus steroid vs steroid alone in low-risk cataract surgery patients. Am J Ophthalmol. 2008;146:554–560.

Relevant disclosures

Miller: None
Trattler: Alcon, Bausch + Lomb, Kala, Johnson & Johnson, Novartis, Omeros, Sun Pharma
Walter: Omeros, Sun Pharma

Contact

Miller
: kmiller@ucla.edu
Trattler: wtrattler@gmail.com
Walter: kwalter@wakehealth.edu

Use of NSAIDs and corticosteroids to stave off CME Use of NSAIDs and corticosteroids to stave off CME
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