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`Pharmaceutical focus
`Getting the scoop on NSAIDs for cataract surgery
`by Maxine Lipner EyeWorld Senior Contributing Writer
`When it comes to cataract surgery, NSAIDs today play an integral
`role, with most practitioners routinely incorporating them into their
`surgical regimens. Here is what leading practitioners told
`EyeWorld about their use of NSAIDs for phacoemulsification cases.
`With patients looking for premium outcomes, Eric D. Donnenfeld,
`MD, clinical professor of ophthalmology, New York University
`Medical Center, stressed that he uses NSAIDs in every cataract
`case. "The evidence shows that without the use of NSAIDs, there's
`about a 5% incidence of macular thickening that can be visually
`significant in patients," he said. "That not only can reduce Snellen
`visual acuity, but also reduces quality of vision, and steroids alone
`don't prevent this in every case."
`
`NSAIDS can knock down
`inflammation and potentially
`stave off a case of CME such
`as this one.
`Source: Phillip Rosenfeld, MD
`
`Eye on inflammation
`
`NSAIDs work to forestall any inflammation that may result from
`the surgery. "NSAIDs inhibit the production of prostaglandins,
`which begins the inflammatory cascade that leads to cystoid macular edema (CME) in susceptible
`patients," Dr. Donnenfeld explained.
`Nick Mamalis, MD, professor of ophthalmology, John A. Moran Eye Center, University of Utah, Salt
`Lake City, also uses NSAIDs in most cataract cases to help calm postoperative inflammation. "What
`NSAIDs do is they help to more quickly reestablish the blood aqueous barrier in the anterior
`segment," Dr. Mamalis said. "The quicker you can calm the inflammation and get the blood
`aqueous barrier reestablished, the better you can prevent sequelae of inflammation." He pointed
`out that NSAIDs have been shown to help decrease the incidence of CME following cataract surgery.
`Elizabeth A. Davis, MD, managing partner, Minnesota Eye Consultants, and adjunct clinical
`professor, University of Minnesota, Twin Cities, Minn., said that in addition to reducing the
`incidence of CME, NSAIDs can have other benefits. "I do think they complement the anti
`inflammatory activity in the anterior segment of the steroid," she said, noting that this can
`ultimately make for faster visual recovery.
`
`NSAIDs in action
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`While the consensus here is to include NSAIDs in nearly all cases, the regimens employed vary. Dr.
`Donnenfeld stressed the need to get NSAIDs on board early. "Since we know that NSAIDs work by
`prohibiting the production of prostaglandins and don't affect the existing prostaglandins, I believe
`that it's important to pretreat these patients," he said. "Treating them the day of surgery doesn't
`give you sufficient antiinflammatory effects, so I start my NSAIDs preoperatively." When possible,
`Dr. Donnenfeld chooses to start NSAIDs 3 days before surgery, but noted that even beginning these
`1 day beforehand can make a big difference. He cited a September 2006 Journal of Cataract &
`Refractive Surgery study that he led that showed a negligible effect of adding NSAIDs an hour
`before surgery.
`"We get a very good effect with 1 day and a little bit better effect with 3 days," Dr. Donnenfeld
`said. "Anywhere between 1 and 3 days (preoperatively) would be the right answer from my
`perspective." In routine cases, Dr. Donnenfeld continues these for 1 month postop. For highrisk
`patients, he recommends starting them on NSAIDs 1 week beforehand and continuing usage for 2
`to 3 months postop, depending on the case. "For example, patients with epiretinal membranes are
`not as high a risk as those with proliferative diabetic retinopathy," Dr. Donnenfeld said. "For a
`patient with proliferative diabetic retinopathy, we start a full week before and go 3 months
`postoperatively." In addition, he carefully monitors these patients to see if they need intravitreal
`injections of antiVEGF or steroids, depending on the retinal complication. He prefers the newer
`generation NSAIDs such as Prolensa (bromfenac, Bausch + Lomb, Rochester, N.Y.) and Ilevro
`(nepafenac, Alcon, Fort Worth, Texas), which are extremely potent, with a much better effect than
`older generation NSAIDs, he said. "They're reformulated to achieve additional penetration into the
`eye. They're also very gentle on the ocular surface." This, he finds, can play a major role from a
`patient compliance perspective. In addition, particularly for those with ocular surface toxicity, Dr.
`Donnenfeld believes that the onceaday dosing of these agents coupled with their buffered vehicles
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`can reduce the risk of keratitis and corneal melting. Sonia H. Yoo, MD, professor of ophthalmology,
`Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, likewise starts
`patients on NSAIDs 2 to 3 days preop and has had them continue until the bottle is empty—typically
`2 to 4 weeks. She, however, typically uses the generic NSAIDs, dosed 4 times a day. "Since I use a
`corticosteroid, which I dose 4 times a day anyway, patients know to take both of them the same
`number of times, so it makes it easier," she said. "But for patients who have a vulnerable ocular
`surface where I think that the burning issue is going to be problematic or if I'm concerned about
`compliance, I might choose a branded NSAID."
`In cases where patients are using generics, Dr. Yoo makes a point of letting them know that they
`might have some temporary burning upon installation. "That way they won't be afraid that they
`have something wrong or that they have some kind of allergy to the drops," she said. Dr. Davis
`routinely starts her patients on Prolensa on the day of cataract surgery, while they are in the
`preoperative area. "I don't have them start it at home unless there's a greater risk for macular
`edema, like diabetes or an epiretinal membrane," she said. In such highrisk cases, Dr. Davis will
`start patients on the NSAID 1 week before surgery and continue for 6 weeks postoperatively. She
`has found that her routine regimen, which also includes Vigamox (moxifloxacin, Alcon) and Pred
`Forte (prednisolone, Allergan, Irvine, Calif.) each 4 times a day, is effective. "Overall my incidence
`of CME with that regimen is very low," she said. "I find the more that you do in terms of
`complicating any medical regimen, the more likely patients are going to get confused about it." She
`prefers to use the brand name Prolensa because with this drug, she knows what she is getting,
`after about 10 years of experience with it. She finds that its infrequent dosing enhances compliance
`and comfort is increased. "It has anesthetic properties, so it is very comfortable to take," she said.
`Dr. Mamalis, on the other hand, tends to use generic NSAIDs for his patients. While he agrees that
`the brandname agents have advantages, he finds that many of his patients do not have coverage
`for these. "In an ideal world, I would certainly recommend some of the newer NSAIDs that you
`don't have to use so often, but in my patient population, often the only medication that's covered is
`a generic ketorolac," Dr. Mamalis said. "This is efficacious, it works well, but it's 4 times a day,
`[and] it tends to burn a little more than some of the other drops."
`While Dr. Mamalis agrees that there is evidence that using a preop NSAID makes sense
`pharmacologically, he finds this is not always practical. "I have difficulty getting my patients to
`adhere to that, so what we usually do is start the NSAIDs on the day of surgery," he said. "When
`we're giving them their preop dilating and antibiotic drops, we will give them the NSAID at that
`time."
`In more vulnerable patients, including those with a history of uveitis or diabetes, Dr. Mamalis
`starts them on the NSAID a week prior to surgery with a slow taper. "We'll have them on a
`prolonged NSAID course following surgery that will often be several weeks long," he said. But in
`routine patients, he will stop the NSAIDs after 2 weeks. However, he pointed out that in Utah, most
`of the patients that he treats are Caucasian and of Northern European ancestry and tend to have
`less significant postop inflammation. "If I'm operating on patients who are Asian, Hispanic, or
`African American, they tend to have more inflammation postoperatively, so I may keep them on
`the NSAID longer before I taper them off," Dr. Mamalis said.
`
`Into the future
`
`Dr. Donnenfeld is very excited about the possibility of intracameral NSAIDs joining the
`armamentarium. Dr. Davis also looks forward to other delivery methods in the future for all
`postoperative drops. She hopes there will be ways to deliver combinations of medications after
`surgery to avoid complex drop regimens. "If there was some method in which we could inject
`something at the end of surgery that combines all of the medications so patients never have to
`take any drops or an insert that we could place in the conjunctival fornix that contained all the
`medication and would dissolve, I think that would be an improvement over what we have because
`older patients may not be very nimble," she said. "Some patients don't have a family member to
`help administer the drop, so the easier we can make it for them, the better."
`
`Reference
`
`Donnenfeld ED, Perry HD, Wittpenn JR, Solomon R, Nattis A, Chou T. Preoperative ketorolac
`tromethamine 0.4% in phacoemulsification outcomes: pharmacokineticresponse curve. J Cataract
`Refract Surg. 2006 Sep;32(9):1474–82.
`
`Editors' note: Dr. Davis has financial interests with Bausch + Lomb. Dr. Donnenfeld has financial
`interests with Alcon, Allergan, and Bausch + Lomb. Dr. Mamalis has no financial interests related
`to his comments. Dr. Yoo has financial interests with Alcon, Allergan, and Bausch + Lomb.
`
`Contact information
`
`Davis: eadavis@mneye.com
`Donnenfeld: ericdonnenfeld@gmail.com
`Mamalis: nick.mamalis@hsc.utah.edu
`Yoo: syoo@med.miami.edu
`
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