European Ophthalmic Review. 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. After cataract surgery, the risk of eye inflammation lasts longer than the risk of eye infection. Inveltys was FDA approved in 2018 and is the only twice-daily corticosteroid for the treatment of postoperative inflammation and pain after ocular surgery. ■. Individuals with hypermature cataract can develop lens-induced (phacoanaphylactic) persistent uveitis or glaucoma and persistent cataract-related inflammation can cause significant tissue damage.7 Mean IOP was statistically significantly higher in dexamethasone-treated patients.22 Comparison of diclofenac 0.1 % and betamethasone 0.1 % in preventing CMO and BAB disruption after small-incision cataract surgery demonstrated a lower incidence of fluorescein angiographic CMO in the diclofenac group (18.8 %) than in the betamethasone group (58.0 %) (n=150, p<0.001).61 There was significantly less anterior chamber flare in the diclofenac group than in the betamethasone group (p<0.05) at one and two weeks, while IOP was significantly higher in the betamethasone group at eight weeks (p=0.0003).61 Surface inflammation and patient comfort were not assessed in this study.61 Strategies for treatment and removal need to be carefully considered, he said. Cataract surgeons agree that postoperative eye drops are not ideal for many reasons, including lack of compliance; low bioavailability; potential toxicity; and expense. 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. West E, Behrens A, McDonnell P, et al., The incidence of endophthalmitis after cataract surgery among the U.S. medicare population increased between 1994 and 2001. “Pain and inflammation are two of the more important concepts we need to embrace and manage for patients undergoing ophthalmic surgery,” he said. 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. The more fluid you run through the eye, the more inflammation you’ll have postop. 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. Henderson B, Kim J, Ament C, et al., Clinical pseudophakic cystoid macular edema- Risk factors for development and duration after treatment. 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. Jonas JB, Kreissig I, Spandau UH, Harder B, Infectious and noninfectious endophthalmitis after intravitreal high-dosage triamcinolone acetonide. 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. What is used after cataract surgery to reduce inflammation? 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. “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. Inflammation is usually treated with steroids or non-steroidal anti-inflammatory drugs (NSAIDs). Minimize the amount of fluid you run through the eye, minimize the total surgical time, and those eyes are virtually pain-free without drops,” Devgan said. The laser can soften the cataract to make the cataract a little easier to emulsify. Not all patient populations are the same, not all cataracts are the same, and not all surgeons have the same experience. In the charity clinic with my UCLA residents, this is the home of the brunescent and white cataract. Topical anti-inflammatory agents are beneficial at removing all the inflammatory factors and clearing the vision, thus they are very important to use after any intraocular surgery. Dextenza could possibly lead to less reliance on postoperative anti-inflammatory drops, Farid said. Her activity is distributed across […], I am delighted to welcome you to the Spring 2020 edition of US Ophthalmic Review. Asbell PA, Dualan I, Mindel J, et al., Age-related cataract. “The other aspect of comfort that is underemphasized is ‘vocal local’ anesthesia. Dexycu (dexamethasone intraocular suspension, EyePoint Pharmaceuticals) was approved in February 2018 and will become available in 2019, Donnenfeld said. Your doctor may conduct several tests, including: 1. 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. The assessment of cells did not differ among the treatments (p=0.165). Non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids are used to prevent and reduce inflammation following cataract surgery, but these two drug classes work by different mechanisms. 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. Is there a cheaper, easier way to do this? Harminder Dua, Division of Ophthalmology and Visual Sciences, B Floor, Eye, Ear, Nose and Throat Centre, University Hospital, Nottingham NG7 2UH, UK. If patients associate pain with the procedure, they may be left with negative feelings about the practice, no matter how much their vision improves. Loteprednol Allergic Conjunctivitis Study Group. 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. 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. “A procedure that ends with a patient having 20/20 vision but experiencing pain during and after the procedure will leave them with a bad experience. Disclosures: Brinton reports he is a consultant for STAAR Surgical, Johnson & Johnson, Nidek and Zeiss. There is no medical treatment for cataracts.2,3 Non-surgical management of cataract includes counselling and use of spectacles or low-vision aids.6,8 Surgical removal of cataract remains the only treatment option for patients with failing vision.3 Cataract surgery is the most commonly performed surgical operation in the Western world.2,9 Small-incision cataract surgery using phacoemulsification has largely replaced extracapsular cataract extraction because of faster healing, smaller wounds and fewer resultant complications,3,6,8 with improved patient outcomes.10 However, post-operative complications, including ocular inflammation after cataract surgery, continue to cause visual impairment, pain and other sequelae among patients. 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. Antibiotic Medication Antibiotic treaments are routinely administered after cataract surgery for the first few weeks. El-Harazi SM, Feldman RM, Control of intra-ocular inflammation associated with 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. Important information The three most typical postoperative classes of medication — antibiotic, steroid and NSAID — can cost more than the surgeon’s fee for cataract surgery if they are the retail brand name medications, Devgan said. It’s certainly not one size fits all,” he said. Brinton JP, et al. These medications are used before and after cataract surgery to help control eye inflammation and reduce the risk of complications. Prospective randomized double-masked study. The more phaco energy you put in the eye, the more inflammation you’ll have postop. “The NSAIDs that we use today are much better than they were in the past. The laser has been shown to reduce the total amount of energy required to emulsify the nucleus during surgery,” he said. Results were limited to English-language, peer-reviewed primary studies and reviews published between the years 2000 and 2010 (inclusive). Advances in pharmacology have allowed ophthalmic surgeons to reduce the incidence of inflammation and infection after cataract surgery. A visual acuity test uses an eye chart to measure how well you can read a series of letters. 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. McGolgin AZ, Raizman MB, Efficacy of topical Voltaren in reducing the incidence of postoperative cystoid macular edema. Important information In 2017, Katsev et al. Holland E, Djalilian A, Sanderson J, Attenuation of ocular hypertension with the use of topical loteprednol etabonate 0.5% in steroid responders after corneal transplantation. Friedlaender MH, Howes J, A double-masked, placebo-controlled evaluation of the efficacy and safety of loteprednol etabonate in the treatment of giant papillary conjunctivitis. Bron A, Denis P, Hoang-Xuan TC, et al., The effects of rimexolone 1% in postoperative inflammation after cataract extraction. World Health Organization, World Health Bulletin on Priority eye diseases: Main causes of visual impairment. Trattler reports he is a consultant for Bausch + Lomb, EyePoint Pharmaceuticals, Ocular Therapeutix, Sun Pharmaceuticals, IanTECH, Lensar and Novartis. Immediately after surgery. FDA approves Inveltys for treatment of inflammation, pain after ocular surgery. Loteprednol Etabonate Giant Papillary Conjunctivitis Study Group I. Ilyas H, Slonim CB, Braswell GR, et al., Long-term safety of loteprednol etabonate 0.2% in the treatment of seasonal and perennial allergic conjunctivitis. Cataract surgery is associated with a risk of ocular infection and toxic inflammation. If you are experiencing inflammation after your cataract surgery, your ophthalmologist will likely prescribe you eyedrops. 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. The interim data showed “extraordinary levels of pain control” with patients receiving the punctal plug NSAID, Donnenfeld said. These are given to reduce inflammation after cataract surgery. Mati Therapeutics announced interim phase 2 clinical trial results evaluating the efficacy of nepafenac delivered via sustained ocular drug delivery platform. These medications have been found to reduce pain, prevent intraoperative miosis, modulate postoperative inflammation, and reduce the incidence of cystoid macular edema (CME). 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. The efficacy of ketorolac tromethamine 0.5 % was compared with LE (0.5 %) in controlling inflammation after cataract surgery in 60 patients pre-operatively and one, three, seven and 30 ± 7 days post-operatively.57 There was no statistically significant difference in post-operative inflammation (objective or subjective cell and flare measurements) or IOP between the two groups.57 A prospective randomised double-masked study compared ketorolac tromethamine (0.5 %) with prednisolone acetate (1 %) in controlling inflammation after cataract surgery in 59 patients for 28 days. 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. A cataract causes the lens to become cloudy, which eventually affects your vision.Cataract surgery is performed by an eye doctor (ophthalmologist) on an outpatient basis, which means you don't have to stay in the hospital after the surgery. Costagliola C, dell'Omo R, Parmeggiani F, et al., Endophthalmitis. McColgin AZ, Heier JS, Control of intraocular inflammation associated with cataract surgery. Regarding slow-release intracanalicular delivery of dexamethasone, Devgan still has questions: “How much of that is going to get to the eye? Dexycu (dexamethasone intraocular suspension) 9% is an extended-release steroid that replaces eye drops after cataract surgery with a single shot. 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. Inflammation after cataract surgery, which can be persistent, remains an undesirable consequence despite many advances in surgical techniques. Donnenfeld reports he is consultant for Alcon, Allergan, Bausch + Lomb, Kala Pharmaceuticals, Mati Therapeutics, Ocular Therapeutix and Omeros. Using a chart or a viewing device with progressively smaller letters, your eye d… Loteprednol Etabonate Postoperative Inflammation Study Group 2. Mentes J, Erakgun T, Afrashi F, Kerci G, Incidence of cystoid macular edema after uncomplicated phacoemulsification. 5. In some cases, the anti-inflammatory eye drops will need to be used longer than that. Ice packs may help reduce inflammation after surgery. Many cataract surgeons begin NSAID medications for their patients preoperatively to reduce intraoperative prostaglandin release and blunt postoperative inflammation. 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 Nonetheless, infection and inflammation still occur, and as such, surgeons must stay abreast of the latest developments in ocular therapeutics. Normally, the lens of your eye is clear. Corticosteroids are effective, but NSAIDs may provide an additional benefit to reduce inflammation when given in combination with corticosteroids. Post-Operative Care After Cataract Surgery. “The NSAID had five times less pain than the placebo group. Additional references were obtained by searching reference lists of identified articles. A double-masked placebo-controlled study. 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. Raizman M, Donnenfeld E, Weinstein A, Clinical comparison of two topical prednisolone acetate 1% formulations in reducing inflammation after cataract surgery. Infusion that starts with a low bottle height, with the height gradually increased during the procedure, can help limit these changes if the patient is uncomfortable, Brinton said. 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. 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. “I am also very aware that ocular surface desiccation occurs during the preoperative setting when patients are numb and not blinking well. Use of LE, a C-20 ester corticosteroid, in the prophylaxis and control of post-cataract surgery inflammation leads to more favourable safety outcomes compared with C-20 ketone corticosteroids. 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. In contrast, corticosteroid therapy (prednisolone acetate) was markedly effective, both when used after the induction of inflammation and when initiated 48 hours previously. Each works the same way, by blocking cyclooxygenase enzymes and hindering production of prostaglandins. Nevanac (nepafenac ophthalmic suspension) is a nonsteroidal anti-inflammatory drug (NSAID). Bromfenac and nepafenac are both excellent NSAIDs. Missotten L, Richard C, Trinquand C, Topical 0.1% indomethacin solution versus topical 0.1% dexamethasone solution in the prevention of inflammation following cataract surgery. A week after surgery, pain scores favored patients who received nepafenac over placebo, according to a Mati Therapeutics press release. Be sure to leave this on as long as the doctor has instructed you to, but do not apply a compression bandage yourself. Therefore, pretreatment with an NSAID is an important step in a surgeon’s protocol to limit postoperative pain. An effective anti-inflammatory treatment regimen, with an improved safety profile that does not significantly elevate IOP, is useful for preventing further inflammation-related complications after cataract surgery. Most surgeons use topical steroids (dexamethasone 0.1% or prednisolone actetate 0.5 or 1%), while some use non-steroidal agents (ketorolac 0.5%). Cataract surgery usually goes well, but it helps to know what to look out for. “When you’re doing the procedure, be very efficient in the eye. PREOPERATIVE NONSTEROIDAL ANTI-INFLAMMATORY DRUG USE. 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 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. 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. 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. Cataract surgery is very common and is generally a safe procedure. 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). “Use of good topical analgesics intraoperatively will also aid with immediate postoperative discomfort,” she said. 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