Carnahan MC, Goldstein DA, Ocular complications of topical, peri-ocular, and systemic corticosteroids. The more you manipulate the iris, the more postop inflammation you’ll see. As well, its intraoperative use aids with postoperative inflammation. Prospective randomized double-masked study. 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 Ophthalmologists generally view visual acuity outcomes as the most important concept in cataract and ophthalmic surgery, but patients perceive pain as equally important, OSN Cornea/External Disease Board Member Eric D. Donnenfeld, MD, said. Cataract surgery is a procedure to remove the lens of your eye and, in most cases, replace it with an artificial lens. You must tailor your treatment to your patient. DeCroos FC, Afshari NA, Perioperative antibiotics and anti-inflammatory agents in cataract surgery. 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). Laurell CG, Zetterstrom C, Effects of dexamethasone, diclofenac, or placebo on the inflammatory response after cataract surgery. Bromfenac and nepafenac are both excellent NSAIDs. Pred Forte (a.k.a. Farid reports she is a consultant for Johnson & Johnson, Allergan, Shire Pharmaceuticals, EyePoint Pharmaceuticals, Kala Pharmaceuticals, CorneaGen and Bio-Tissue. When using a steroid and NSAID in combination, it is possible to use a topical steroid at a lower frequency per day as compared with using a topical steroid without an NSAID, OSN Technology Section Editor William B. Trattler, MD, said. Ice packs may help reduce inflammation after surgery. What works well in my hands in a Beverly Hills setting may not work the same, even if it’s my own hand, in this underserved part of Los Angeles at our county teaching hospital. CBD is short for cannabidiol, a chemical from the hemp plant that has become increasingly popular in recent years because it has no intoxicating effects. The best control of surface inflammation and highest patient comfort were achieved with prednisolone (p=0.041).62, Because NSAIDs and corticosteroids have different mechanisms of action, they may be synergistic in the prevention and treatment of ocular inflammation after cataract surgery. Findl O, Redefining the Treatment Paradigm for Post-operative Inflammation Control –The Role of Topical Non-steroidal Anti-inflammatory Drugs. Normally, the lens of your eye is clear. Interestingly, there are no studies showing that antibiotic eye drops decrease the infection rate. Drugs, better surgical techniques and new technologies can limit the amount of pain and inflammation a patient experiences after undergoing cataract surgery. In 2017, Katsev et al. 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 BromSite was approved by the FDA in 2016 to prevent pain and treat inflammation in cataract surgery and is delivered via the DuraSite vehicle, which is a polymer-based formulation that increases the drug’s residence time on the ocular surface. 5. 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. What is used after cataract surgery to reduce inflammation? Injectable steroids under the conjunctiva, such as subconjunctival dexamethasone or a sub-Tenon’s injection of triamcinolone, or intracamerally with appropriate medications can result in a better anti-inflammatory response after cataract surgery, according to Devgan. Younger patients and highly myopic patients can be more sensitive to changes in anterior chamber fluid volume and IOP. Solomon R, Donnenfeld ED, Recent advances and future frontiers in treating age-related cataracts. NSAIDs are cyclo-oxygenase inhibitors that work by suppressing production of prostaglandins. For patients with minor swelling, Durezol may not be necessary. “The NSAIDs that we use today are much better than they were in the past. Advances in pharmacology have allowed ophthalmic surgeons to reduce the incidence of inflammation and infection after cataract surgery. We begin with an insightful Expert Interview with Deborah K VanderVeen, from Boston Children’s Hospital, about the rationale for the use of orthokeratology for the […], US Ophthalmic Review. Dell SJ, Shulman DG, Lowry GM, Howes J, A controlled evaluation of the efficacy and safety of loteprednol etabonate in the prophylactic treatment of seasonal allergic conjunctivitis. Patients also have quieter eyes, which I believe is due to the intracameral use of the ketorolac.”. CMO was noted in one eye in the betamethasone monotherapy treatment group. “I am also very aware that ocular surface desiccation occurs during the preoperative setting when patients are numb and not blinking well. Patients are more comfortable having already become familiar with our office staff and environment, as opposed to having to go to a hospital or ambulatory surgical center,” he said. The … Patient communication during cataract surgery. The delivery systems have improved, specifically with nepafenac available as Ilevro 0.3% from Alcon, which is once-a-day dosing, and bromfenac available as Prolensa 0.07% from Bausch + Lomb or as BromSite 0.075% (Sun Ophthalmics),” Donnenfeld said. Cataract surgery is very common and is generally a safe procedure. Anti-inflammatory drugs should be given before surgery. Tranos PG, Wickremasinghe SS, Stangos NT, et al., Macular edema. 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. Asbell P, Howes J, A double-masked, placebo-controlled evaluation of the efficacy and safety of loteprednol etabonate in the treatment of giant papillary conjunctivitis. Therefore, pretreatment with an NSAID is an important step in a surgeon’s protocol to limit postoperative pain. Sun R, Gimbel HV, Effects of topical ketorolac and diclofenac on normal corneal sensation. 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). “When you’re doing the procedure, be very efficient in the eye. The medications can cost as much as $200 each, he 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. The FDA accepted a new drug application for a lower concentration formulation — submicron loteprednol etabonate ophthalmic gel 0.38% — intended for less frequent dosing, and a PDUFA decision is pending Feb. 25. 6. While corticosteroids are traditionally the therapy of choice for inflammation, their long-term use for managing ocular inflammation can produce significant adverse events. This limitation of traditional corticosteroids led to the development of C-20 ester corticosteroids through retrometabolic drug design. None of the patients in the group receiving peri-operative diclofenac developed CMO compared with 12 % of the patients in the group receiving post-operative treatment only.65 “Buffered solutions with higher concentrations of lidocaine can also be used. Rowen S, Preoperative and postoperative medications used for cataract surgery. Patients can expect to use their anti-inflammatory eye drops for three to six weeks after surgery. The FDA approved Dextenza (dexamethasone ophthalmic insert 0.4 mg, Ocular Therapeutix), the first intracanalicular insert to deliver dexamethasone to treat postoperative ocular pain for up to 30 days, in December. Inveltys was FDA approved in 2018 and is the only twice-daily corticosteroid for the treatment of postoperative inflammation and pain after ocular surgery. “These techniques minimize the issue of noncompliance and trauma from medication bottle tips hitting the ocular surface postoperatively. In addition to the newly approved Dextenza, new drugs and delivery systems are being developed to improve pain and inflammation management after ocular surgery. Keates R, McGowan K, Clinical trial of flurbiprofen to maintain pupillary dilation during cataract surgery. Stern GA, Factors affecting the efficacy of antibiotics in the treatment of experimental postoperative endophthalmitis. Wittpenn J, Silverstein S, Heier J, et al., StudyGroup ACME, A randomized, masked comparison of topical ketorolac 0.4% plus steroid vs steroid alone in low-risk cataract surgery patients. 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. Mentes J, Erakgun T, Afrashi F, Kerci G, Incidence of cystoid macular edema after uncomplicated phacoemulsification. To determine whether you have a cataract, your doctor will review your medical history and symptoms, and perform an eye examination. I’m all for more products and new products that work well, but we need to balance the cost-to-benefit ratio for our patients,” he said. “The NSAID had five times less pain than the placebo group. Tell us what you think about 11 Compared with NSAIDs, corticosteroids have a wider range of activity in relieving inflammation (see Figure 1 ). Hsu JK, Johnston WT, Read RW, et al. Leibowitz H, Ryan W, Kupferman A, DeSantis L, Effect of concurrent topical corticosteroid and NSAID therapy of experimental keratitis. Baltussen R, Sylla M, Mariotti S, Cost-effectiveness analysis of cataract surgery: a global and regional analysis. We consider pain and inflammation as being extremely important in our patients,” Donnenfeld said. Hirneiss C, Neubauer AS, Kampik A, Schonfeld CL, Comparison of prednisolone 1%, rimexolone 1% and ketorolac tromethamine 0.5% after cataract extraction: a prospective, randomized, double-masked study. Treatment with peri-operative ketorolac and post-operative prednisolone acetate significantly reduced the incidence of both CMO and macular thickening in cataract surgery patients, indicating that the combination of a corticosteroid and an NSAID was synergistic in the prevention of inflammation following surgery.64 Similarly, treatment with diclofenac for two days pre-operatively and four weeks post-operatively plus steroid post-operatively reduced the incidence of CMO in a study of 60 patients undergoing small-incision cataract surgery as compared with treatment with diclofenac and steroid post-operatively only. Assil KK, Massry G, Lehmann R, et al., Control of ocular inflammation after cataract extraction with rimexolone 1% ophthalmic suspension. The laser can soften the cataract to make the cataract a little easier to emulsify. Although corticosteroids and non-steroidal anti-inflammatory drugs (NSAIDs) have traditionally been used to treat inflammation, prophylactically as well as post-operatively, there are no established guidelines for the treatment of inflammation induced by cataract surgery. “In addition to maintaining pupil size and preventing inflammation that causes miosis, we find that patients’ eyes are optimal with the use of Omidria, and it’s very effective in patients with floppy iris syndrome. Flach AJ, Cyclo-oxygenase inhibitors in ophthalmology. Speaker M, Milch F, Shah M, et al., Role of external bacterial flora in the pathogenesis of acute postoperative endophthalmitis. Both drugs were well tolerated but conjunctival hyperaemia was less pronounced in the dexamethasone group on post-operative day 30 (p=0.046). The use of the miLOOP (IanTECH/Zeiss) for a more dense cataract can help break the cataract into smaller pieces intraocularly and make it easier to remove. In the charity clinic with my UCLA residents, this is the home of the brunescent and white cataract. This allows LE to be active at the glucocorticoid receptor, its site of action, and subsequently to undergo predictable hydrolysis to inactive carboxylic acid metabolites by naturally occurring ocular esterases. 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. In a retrospective chart review of 450 consecutive patients who had uncomplicated cataract surgery, those patients treated with prednisolone alone had a higher incidence of visually significant macular oedema as documented by optical coherence tomography (OCT) compared with those treated with both prednisolone and nepafenac (five patients versus no patients, respectively, p=0.0354).63 In a clinical trial investigating the use of ketorolac (0.4 %) in combination with prednisolone acetate (1 %), a notably reduced mean retinal thickening was observed through OCT in patients receiving combination therapy compared with patients receiving only prednisolone acetate (3.9 versus 9.6 μm, p=0.003).64 No patients in the combination group and five patients in the prednisolone group developed clinically apparent CMO (p=0.032). A week after surgery, pain scores favored patients who received nepafenac over placebo, according to a Mati Therapeutics press release. In a separate 2011 study in the American Journal of Ophthalmology, patients treated with Durezol experienced less corneal edema than those treated with prednisolone acetate. Ketorolac ophthalmic (for the eye) is used to relieve eye itching caused by seasonal allergies. The laser has been shown to reduce the total amount of energy required to emulsify the nucleus during surgery,” he said. Loteprednol Etabonate Postoperative Inflammation Study Group 2. Nonsteroidal antiinflammatory drugs (NSAIDs) have become an important adjunctive tool for surgeons performing routine and complicated cataract surgery. Using a chart or a viewing device with progressively smaller letters, your eye d… Scientific Department, The Royal College of Ophthalmologists, London, 2004. A 0.5 mg to 1 mg preservative-free intracameral dose of triamcinolone can also provide a patient with a good steroid response for a few days before it is washed out. Cataracts are a major cause of blindness and severe visual impairment, leading to bilateral blindness in an estimated 20 million people worldwide in 2004.1 Over half of all persons over the age of 65 develop age-related cataracts with visual disability.2 Globally, the number of cataract cases is expected to increase as populations age and lifespans increase.3 In the US alone, the number of persons with cataracts is projected to reach 30.1 million by 2020.4 Cataracts are the most common cause of vision loss in developed and developing countries.5,6 An intracameral mixture of lidocaine 1% and phenylephrine 1.5% in balanced salt solution can also improve outcomes. One such C-20 ester corticosteroid, loteprednol etabonate (LE), is the Δ1-cortienic acid etabonate derivative of prednisolone acetate but with a 17α-chloromethyl ester at the C-20 position instead of a ketone (see Figure 2). There are a variety of topical steroids available, and each has its own benefits. Topical anti-inflammatory agents are routinely used after cataract surgery to control post-operative inflammation. One patient receiving ketorolac tromethamine developed corneal erosion. 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. “From a comfort standpoint, we consider it a significant advantage to have an office facility in which we can perform vision correction surgery with refractive IOLs. Congdon N, Vingerling J, Klein B, et al., Eye Diseases Prevalence Research Group, Prevalence of cataract and pseudophakia/aphakia among adults in the United States. Holzer MP, Solomon KD, Sandoval HP, Vroman DT, Comparison of ketorolac tromethamine 0.5 % and loteprednol etabonate 0.5 % for inflammation after phacoemulsification: prospective randomized double-masked study. Even though NSAIDs work by inhibiting prostaglandin production, they do not influence preformed prostaglandin, according to Donnenfeld. 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. Schacke H, Docke WD, Asadullah K, Mechanisms involved in the side effects of glucocorticoids. Inflammation after cataract surgery, which can be persistent, remains an undesirable consequence despite many advances in surgical techniques. 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. It is likewise true that eye medications (drops) she would use after a surgery like that or to treat her eye pressure and inflammation can cause pupil size modifications and ptosis, so once again, essential concerns for the surgeon/treating physician. Current standard-of-care for inflammation follow cataract surgery involves self-administering medicated eye-drops for a period of weeks. These claims have not been verified by the U.S. Food and Drug Administration. Solomon KD, Cheetham JK, DeGryse R, et al., Topical ketorolac tromethamine 0.5% ophthalmic solution in ocular inflammation after cataract surgery. Nevanac (nepafenac ophthalmic suspension) is a nonsteroidal anti-inflammatory drug (NSAID). Cataract surgery is associated with a risk of ocular infection and toxic inflammation. Prolensa™ (bromfenacophthalmic solution) is a prescription medication used to reduce inflammation and pain after cataract surgery. A double-masked placebo-controlled study. Loteprednol Allergic Conjunctivitis Study Group. “I also use femtosecond laser cataract surgery. While corticosteroids have a broader mechanism of action – inhibiting both the cyclo-oxygenase and lipoxygenase pathways through inhibition of phospholipase A2 – traditional corticosteroids are limited in that they lead to elevated IOP. They are intended to help decrease the chance of infection… inside the eye. Drug delivery systems are the future of pharmaceuticals in ophthalmology,” he said. Mike: I also have pain 2 years later. Nevanac may also be used for other purposes not listed in this medication guide. Dexycu. “Pain and inflammation are two of the more important concepts we need to embrace and manage for patients undergoing ophthalmic surgery,” he said. “That’s what I’m doing postop,” he said, referring to the preservative-free triamcinolone in the anterior chamber. Cantrill HL, Palmberg PF, Zink HA, et al., Comparison of in vitro potency of corticosteroids with ability to raise intraocular pressure. Simone J, Pendelton R, Jenkins J, Comparison of the efficacy and safety of ketorolac tromethamine 0.5% and prednisolone acetate 1% after cataract surgery. 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. She graduated in pharmacology and statistics (MSc) and completed her PhD thesis in anatomy. Dell SJ, Lowry GM, Northcutt JA, et al., A randomized, double-masked, placebo-controlled parallel study of 0.2% loteprednol etabonate in patients with seasonal allergic conjunctivitis. Devgan reports no relevant financial disclosures. “It could eliminate the need for topical or clinical steroids in most patients after cataract surgery,” Donnenfeld said. Bromfenac became available in the EU in 2011. This corticosteroid, alone or in combination with NSAIDs, may provide effective and safe inflammation control, especially for high-risk patients, and may overcome concerns regarding side effects associated with traditional C-20 ketone corticosteroids. Corticosteroids are effective, but NSAIDs may provide an additional benefit to reduce inflammation when given in combination with corticosteroids. 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. Results were limited to English-language, peer-reviewed primary studies and reviews published between the years 2000 and 2010 (inclusive). “All of these are excellent inhibitors of pain and inflammation. This edition features some wide-ranging and insightful articles from top names in ophthalmology from around the globe. To avoid ocular surface irritation and dryness in the early postoperative period, we avoid [balanced salt solution] irrigation of the eye and instead, at the beginning of the treatment, place a dispersive viscoelastic such as hydroxypropyl methylcellulose on the ocular surface for patient comfort,” Brinton said. Pre- and postop topical steroids reduce inflammation and are helpful at reducing corneal swelling. Regarding slow-release intracanalicular delivery of dexamethasone, Devgan still has questions: “How much of that is going to get to the eye? This easily placed slow-release medication with minimal potential of side effects has the potential to significantly change our postoperative medication landscape,” she said. Important information Corticosteroids and non-steroidal anti-inflammatory drugs (NSAIDs) provide active inhibition in the inflammatory cascade; however, these agents do so at different locations in the pathway. 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. Flach AJ, Lavelle CJ, Olander KW, et al., The effect of ketorolac tromethamine solution 0.5% in reducing postoperative inflammation after cataract extraction and intraocular lens implantation. After cataract surgery, the risk of eye inflammation lasts longer than the risk of eye infection. The triamcinolone gives the eye a “little extra boost” and helps quiet the eye almost immediately, OSN Healio.com Section Editor Uday Devgan, MD, said. “As far as other nonsteroidals, we routinely use Omidria at the time of cataract surgery,” Donnenfeld said. Inflammation is usually treated with steroids or non-steroidal anti-inflammatory drugs (NSAIDs). 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. Corticosteroids are traditionally used for short-term control of ocular inflammation 33 and are a mainstay of treatment regimens following cataract surgery. Cataract surgeons agree that postoperative eye drops are not ideal for many reasons, including lack of compliance; low bioavailability; potential toxicity; and expense. Immediately after surgery. Is there a cheaper, easier way to do this? Dextenza could possibly lead to less reliance on postoperative anti-inflammatory drops, Farid said. When administered together, NSAID plus corticosteroid therapy was more effective for mean decrease in corneal inflammatory activity in rabbits than treatment with either drug alone, regardless of whether therapy was initiated before or after the inflammatory event.66 El-Harazi SM, Feldman RM, Control of intra-ocular inflammation associated with cataract surgery. Typically, the antibiotic drops are used for about a week, while the anti-inflammatory drops are used three to six weeks or longer in some cases. Henderson B, Kim J, Ament C, et al., Clinical pseudophakic cystoid macular edema- Risk factors for development and duration after treatment. Post-Operative Care After Cataract Surgery. The goal of preoperative treatment with an NSAID is to manage inflammation and pain before the procedure, OSN Cornea/External Disease Board Member Marjan Farid, MD, said. If you’re an experienced surgeon, you can be very efficient and minimize the phaco energy by using the phaco chop technique, as well as phaco power modulation. Normally, the lens of your eye is clear. Her activity is distributed across […], I am delighted to welcome you to the Spring 2020 edition of US Ophthalmic Review. The nanoparticle formulation is delivered via Kala’s mucus-penetrating technology. 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. Chang DF, Garcia IH, Hunkeler JD, Minas T, Phase II results of an intraocular steroid delivery system for cataract surgery. When surgeons are determining the protocol for patients to follow after cataract surgery, they should remember to tailor their postoperative regimen to their specific patient population in their specific clinic, Devgan said. Omidria (phenylephrine 1% and ketorolac 0.3% intraocular solution, Omeros) is the only FDA-approved intracameral NSAID-containing injection that reduces inflammation and maintains mydriasis, according to Farid. Sometimes, these medications can be injected into the eye at the time of surgery. Novack GD, Howes J, Crockett RS, Sherwood MB, Change in intraocular pressure during long-term use of loteprednol etabonate. When beginning the procedure, the more phaco energy you put in the management of postoperative inflammation following cataract.. Al., age-related cataract coming down the line, a topical corticosteroid, was FDA approved in for! Many options here, some more expensive than others in postoperative inflammation corneal melting associated with cataract surgery C! In anatomy optimize cataract surgery, which can be more sensitive to changes anterior. What is used to reduce swelling, Durezol may not be necessary corticosteroid for the few. 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