Advances in pharmacology have allowed ophthalmic surgeons to reduce the incidence of inflammation and infection after cataract surgery. In a study in rabbits, NSAID therapy (suprofen) was shown to be effective when started 48 hours prior to the induction of inflammation; however, it was ineffective when administered immediately after induction of inflammation. You know your patient and your population, your nuances, better than everyone else. Ketorolac ophthalmic (for the eye) is used to relieve eye itching caused by seasonal allergies. This article was funded by Bausch & Lomb. Pflugfelder SC, Maskin SL, Anderson B, et al., A randomized, double-masked, placebo-controlled, multicenter comparison of loteprednol etabonate ophthalmic suspension, 0.5%, and placebo for treatment of keratoconjunctivitis sicca in patients with delayed tear clearance. Diclofenac 0.1 % and dexamethasone 0.1 % were equally effective in reducing inflammation in post-cataract patients (n=180) as measured with laser flare photometry at days three and eight and at two weeks and one month following cataract surgery, while both were more effective than placebo. There are a variety of topical steroids available, and each has its own benefits. This limitation of traditional corticosteroids led to the development of C-20 ester corticosteroids through retrometabolic drug design. A 2016 review by Hoffman and colleagues groups the commercially available NSAIDs into six major classifications: salicylates, fenamates, indoles, phenylalkanoic acids, phenylacetic acids and pyrazolones. “Cataract surgeons will be very happy with the approval of Dextenza for the treatment of postoperative pain. The rapid metabolism of LE results in a lower propensity to induce IOP elevation compared with C-20 ketone corticosteroids, even when administered to known corticosteroid responders.38 LE has been shown to be a safe corticosteroid when used to treat a number of ocular inflammatory conditions, including giant papillary conjunctivitis, seasonal allergic conjunctivitis, uveitis, dysfunctional tear syndrome and post-cataract surgery inflammation.20,21,27,38–45 Cataract surgery is very common and is generally a safe procedure. Jonas JB, Kreissig I, Spandau UH, Harder B, Infectious and noninfectious endophthalmitis after intravitreal high-dosage triamcinolone acetonide. Inflammation after cataract surgery, which can be persistent, remains an undesirable consequence despite many advances in surgical techniques. “As far as other nonsteroidals, we routinely use Omidria at the time of cataract surgery,” Donnenfeld said. These studies demonstrate that NSAIDs may work synergistically with corticosteroid therapy to provide effective control of inflammation and its effect on macular thickness after cataract surgery.55,63–66 Moreover, combination NSAID/steroid therapy in the setting of acute, visually significant pseudophakic CMO appears to offer treatment benefits over monotherapy regimens.67,68, Corticosteroids and NSAIDs are the mainstay topical therapies for post-operative inflammation following cataract surgery. Prospective randomized double-masked study. Relevant publications were identified through searches of PubMed, Embase and the Cochrane Library using the following search terms: cataract, cataract surgery, postsurgical inflammation, anti-inflammatory and corticosteroid. Your doctor may prescribe eyedrops or other medication to prevent infection, reduce inflammation and control eye pressure. “A Beverly Hills cataract is removed pretty easily because the modest nuclear sclerosis means that it’s not dense. Nepafenac ophthalmic suspension may also be used for other purposes not listed in this medication guide. Her activity is distributed across […], I am delighted to welcome you to the Spring 2020 edition of US Ophthalmic Review. The efficacy of indomethacin 0.1 % was compared with that of dexamethasone 0.1 % in a randomised double-masked study of 145 patients undergoing cataract surgery.60 Protein flare and cells decreased in both groups, with a difference in favour of indomethacin for cells at post-operative day 30 (p=0.046). Dextenza’s approval is another positive addition to a surgeon’s armamentarium to limit pain and inflammation after cataract surgery. PREOPERATIVE NONSTEROIDAL ANTI-INFLAMMATORY DRUG USE. This easily placed slow-release medication with minimal potential of side effects has the potential to significantly change our postoperative medication landscape,” she said. What is used after cataract surgery to reduce inflammation? According to a 2011 study published in Clinical Ophthalmology, Durezol is a more potent steroid to use after cataract surgery compared with the previous gold standard prednisolone acetate. Antibiotic eyedrops are used after cataract surgery to prevent infection and steroid and NSAID (non-steroidal anti-inflammatory drug) eyedrops are used to reduce and eliminate inflammation. Redness and swelling are common within two weeks after surgery. Donnenfeld said he continues NSAIDs for 4 weeks postoperatively in his cataract patients but may extend NSAID use to 2 or 3 months for patients who experience extreme inflammation or those with inflammatory diseases, uveitis or diabetes. Nonsteroidal antiinflammatory drugs (NSAIDs) have become an important adjunctive tool for surgeons performing routine and complicated cataract surgery. J Cataract Refract Surg 2003;29:2:250-256. The nanoparticle formulation is delivered via Kala’s mucus-penetrating technology. Asano S, Miyake K, Ota I, et al., Reducing angiographic cystoid macular edema and blood-aqueous barrier disruption after small-incision phacoemulsification and foldable intraocular lens implantation: multicenter prospective randomized comparison of topical diclofenac 0.1 % and betamethasone 0.1 %. El-Harazi SM, Feldman RM, Control of intra-ocular inflammation associated with cataract surgery. Mentes J, Erakgun T, Afrashi F, Kerci G, Incidence of cystoid macular edema after uncomplicated phacoemulsification. A review of studies published in the last 10 years indicates that C-20 ester corticosteroids provide effective control of post-cataract surgery inflammation without the elevation of IOP. Bromfenac became available in the EU in 2011. On the day of surgery, Farid gives patients topical proparacaine eye drops before dilation, as well as topical TetraVisc (tetracaine 0.5%, OcuSoft) to manage intraoperative pain. The physical trauma associated with cataract surgery, including disruption of the blood–aqueous barrier (BAB), can induce an inflammatory response and the release of inflammatory mediators such as prostaglandins and leukotrienes from arachidonic acid (see Figure 1). Supported by an independent educational grant from Alcon. Bartlett JD, Horwitz B, Laibovitz R, Howes JF, Intraocular pressure response to loteprednol etabonate in known steroid responders. The authors have no conflicts of interest to declare. Bromfenac 0.075% in the DuraSite™ vehicle is a newly-approved formulation which has been shown to be efficacious and safe for use in cataract Different forms of monotherapy with corticosteroids or NSAIDs have been compared in the prophylaxis and control of post-cataract surgery inflammation. The development of post-operative inflammation varies across patients (e.g., patients on prostaglandin treatment for glaucoma or hypertension before cataract surgery may be at higher risk of post-surgical inflammation and complications such as CMO).19 Pupillary constriction during extracapsular cataract extraction is mainly caused by prostaglandins resulting from surgical trauma, which can be prevented by pre-operative use of topical corticosteroids or NSAIDs.20–26 Patients with pre-existing inflammation in the eye, such as those with dysfunctional tear syndrome, are susceptible to increased inflammation following cataract surgery.27 Patients showing signs of rosacea, which correlates with a high incidence of evaporative dry eye syndrome, have significantly improved visual outcomes when treated with a corticosteroid prior to surgery.27 In dysfunctional tear syndrome, tear hyperosmolarity leads to production of pro-inflammatory mediators.27 Inhibiting this process with the use of pre-operative NSAIDs and corticosteroids may reduce the effects of dysfunctional tear syndrome as well as the risk of inflammation after cataract surgery.16,27,28 A patient who is familiar with the operating environment, the surgeon and the clinic staff can be more at ease during a procedure and experience less discomfort postoperatively, Brinton said. Patients want to hear the doctor’s voice and want staff to tell them what to expect next through the process. “Pain and inflammation are two of the more important concepts we need to embrace and manage for patients undergoing ophthalmic surgery,” he said. This design modification allows the corticosteroid to be active at its site of action and then undergo predictable hydrolysis to inactive metabolites, resulting in reduced side effects. “I also use femtosecond laser cataract surgery. Asbell PA, Dualan I, Mindel J, et al., Age-related cataract. Histopathology of corneal melting associated with diclofenac use after refractive surgery. Ice packs may help reduce inflammation after surgery. Solomon KD, Cheetham JK, DeGryse R, et al., Topical ketorolac tromethamine 0.5% ophthalmic solution in ocular inflammation after cataract surgery. Anti-inflammatory drugs should be given before surgery. However extended use requires careful monitoring and reporting. Current standard-of-care for inflammation follow cataract surgery involves self-administering medicated eye-drops for a period of weeks. Stewart RS, Controlled evaluation of fluorometholone acetate and loteprednol etabonate in the treatment of postoperative inflammation following cataract surgery, Abstract B265. Nevertheless, due to a potential class effect of corneal toxicity and melting with NSAIDs, the use of NSAIDs in patients with pre-existing compromised corneal epithelium may need to be limited (unless the risk of CMO outweighs the risk of corneal adverse events). Ketorolac was as effective and well tolerated as prednisolone in controlling post-operative inflammation and pain after cataract surgery.58 Ketorolac tromethamine (0.5 %) and rimexolone 1 % were compared for controlling post-operative inflammation in 36 patients that had undergone cataract surgery; there were no statistically significant differences between the groups in cells, flare or IOP.59 As the authors point out, the original design of the lens […], Get the latest clinical insights from touchOPHTHALMOLOGY, Treatment of Post-operative Inflammation following Cataract Surgery – A Review, http://doi.org/10.17925/EOR.2012.06.02.98. Floaters appeared after having cataract surgery. The two main classifications of medications surgeons use to control postoperative pain and inflammation are NSAIDs for reducing pain and steroids for reducing postoperative inflammation. “It makes you wonder, is there a role for lower costs? Pain is an important concept of patients having surgery. Additional references were obtained by searching reference lists of identified articles. Shulman DG, Lothringer LL, Rubin JM, et al., A randomized, double-masked, placebo-controlled parallel study of loteprednol etabonate 0.2% in patients with seasonal allergic conjunctivitis. A week after surgery, pain scores favored patients who received nepafenac over placebo, according to a Mati Therapeutics press release. Click here to read the , “How do you balance cost of postoperative steroids and NSAIDs and still keep pace with innovative medications?”, Get the latest news and education delivered to your inbox, Receive an email when new articles are posted on, Please provide your email address to receive an email when new articles are posted on, www.eyerounds.org/tutorials/Communication-Cataract-Surgery.htm, www.healio.com/ophthalmology/cataract-surgery/news/online/%7Bef827c6d-648b-4a9f-8a93-7fab69b73622%7D/fda-approves-inveltys-for-treatment-of-inflammation-pain-after-ocular-surgery, www.businesswire.com/news/home/20180904005058/en/Mati-Therapeutics-Interim-Phase-II-Nepafenac-Clinical, investors.ocutx.com/phoenix.zhtml?c=253650&p=irol-newsArticle&ID=2378993. Loteprednol etabonate ophthalmic suspension 0.5 % is the only topical C-20 ester corticosteroid approved for use in the treatment of corticosteroid-responsive inflammatory conditions including post-operative ocular inflammation. Patients dosed either once a day or twice a day for a median of 27.1 days experienced reduced inflammation compared with patients treated with prednisolone acetate. In the charity clinic with my UCLA residents, this is the home of the brunescent and white cataract. It’s certainly not one size fits all,” he said. NSAIDs are cyclo-oxygenase inhibitors that work by suppressing production of prostaglandins. Dextenza has completed Phase 3 evaluation for the treatment of ocular pain and inflammation following ophthalmic surgery, but is currently limited to investigational use only. It belongs to a group of medicines known as nonsteroidal anti-inflammatory drugs, or NSAIDsfor short. In a recent review, bromfenac twice daily (BID) was found to demonstrate an early and sustained level of clinical activity with little burning and stinging and minimal adverse events in the treatment of ocular inflammation following cataract surgery.56 Preclinical studies with bromfenac demonstrated that the addition of bromine increased ocular penetration, suggesting that bromfenac BID may be as potent as other NSAIDs administered more frequently but with less potential for corneal toxicity. S protocol to manage pain and swelling are common within two weeks after surgery, pain after surgery! Pathogenesis of acute postoperative endophthalmitis editorial assistance I make sure that the ocular surface is well lubricated to minimize punctate. As agents that can neutralize their action following their release are not available history and symptoms, perform... Nonsteroidal antiinflammatory drugs ( NSAIDs ) are steroids, and burning or after! 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