This article is more than 5 years old. Information may no longer be current.

NSAIDs crucial in preventing cystoid macular edema

Add topic to email alerts

Receive an email when new articles are posted on

Please provide your email address to receive an email when new articles are posted on .

Subscribe

Added to email alerts

You've successfully added to your alerts. You will receive an email when new content is published.

Click Here to Manage Email Alerts

You've successfully added to your alerts. You will receive an email when new content is published.

Click Here to Manage Email Alerts

Back to Healio

We were unable to process your request. Please try again later. If you continue to have this issue please contact customerservice@slackinc.com.

Back to Healio

Cystoid macular edema (CME) is a common problem in ophthalmic practices, and the appropriate use of topical non-steroidal anti-inflammatory drugs (NSAIDs) before and after cataract surgery can nearly eliminate CME in most cases, according to Michael B. Raizman, MD, Director, Cornea and Anterior Segment Service of the New England Eye Center and Associate Professor of Ophthalmology at Tufts University School of Medicine in Boston, Ma. Non-steroidal drugs are also helpful in refractive surgery for controlling pain and inflammation, he said.

Increased use of NSAIDs

The use of NSAIDs made a comeback after safety concerns caused many ophthalmologists to discontinue using them, said Raizman. New non-steroidal agents are safe and well tolerated by nearly all patients, and ophthalmologists are increasing the use of NSAIDs during cataract surgery, he added.

The main impetus for the recent increase in the use of non-steroidal drugs is patient demand for good surgical outcomes and an understanding by ophthalmologists that cataract surgery has become a refractive procedure with the advent of refractive IOLs.

“Physicians can no longer tolerate 20/30 or 20/40 vision outcomes in cataract patients who have no other ocular disorders,” said Dr. Raizman. “Patients demand increased Snellen visual acuity and an increase in overall quality of vision, especially with the explosive growth of refractive IOLs and the heightened expectations of the cash-paying patient.”

Non-steroidal agents can contribute to surgeons’ ability to provide better quality of vision to their patients, said Dr. Raizman. He claims many ophthalmologists are using topical anesthesia during cataract surgery, and believes there is no question that patients are more comfortable when an NSAID is used before cataract surgery with topical anesthesia.

Synergistic treatments

Prostaglandins are a major cause of eye inflammation, according to Dr. Raizman. They increase vascular permeability in all of the eye structures, anterior and posterior, while also contributing to myosis and overall patient discomfort.

“Ophthalmologists need to be especially concerned about the prostaglandins that increase vascular permeability and swelling of the macula after cataract surgery,” said Dr. Raizman. “They also need a drug regimen that can penetrate ocular tissue to inhibit this response.

“Pre-clinical data showed nepafenac (Nevanac 0.1% ophthalmic suspension, Alcon) to be effective in reducing inflammation in the back of the eye,” he continued.

A synergism exists between steroids and NSAIDs in treating these concerns. Dr. Raizman believes regimens should include the use of both, rather than one or the other. “The use of non-steroidal drugs as an additive to the effect of steroids prior to cataract surgery reduces postoperative inflammation,” he said, adding that NSAIDs can also keep the pupil more widely dilated for increased vision of the surgical field for the physician. Finally, Dr. Raizman said, NSAIDs are an excellent adjunct in decreasing pain and discomfort in patients.

Stopping macular edema

Cystoid macular edema is the most common cause of significant decrease in vision after routine, uncomplicated cataract surgery. Non-steroidal agents help prevent macular edema following surgery. Macular edema tends to occur 4 weeks to 6 weeks postoperatively. A pivotal study has now shown 12% of patients will develop macular edema after uncomplicated cataract surgery, even after an aggressive regimen of topical steroids. The development is unacceptable, according to Dr. Raizman.

“Optical coherence tomography (OCT) aids in defining and quantifying the amount of retinal swelling occurring after cataract surgery,” he explained. “I have seen a number of patients with 20/20 vision or 20/25 vision who still complain of metamorphopsia and other ocular distortions. In these cases, OCT can reveal that there is swelling adjacent to the fovea.”

Dr. Raizman advised that non-steroidal agents need to be used before and after surgery on patients at a high risk of developing macular edema. High-risk patients include those with pre-existing ocular inflammation, especially recurrent or chronic iritis, patients with epiretinal membranes and patients with diabetes, especially patients with diabetic retinopathy.

Some studies show 50% to 60% of patients with diabetic retinopathy will have worsening of macular edema with uncomplicated cataract surgery, said Dr. Raizman, who believes these patients deserve special attention. Additionally, he cautioned that patients who have had ocular vascular disease or vein occlusions in the past, patients with retinitis pigmentosa and any patient who has had excessive inflammation and macular edema in the contralateral eye deserve longer treatment with NSAIDs after surgery.

“I presented a study 6 years ago in which my colleagues and I compared the use of non-steroidal drugs paired with corticosteroids to the use of corticosteroids alone around cataract surgery,” said Dr. Raizman. “We discovered that 12% of patients with no pre-existing risk factors treated with corticosteroids 4 weeks prior to cataract surgery developed significant cystoid macular edema as defined by a decrease in visual function.” Patients who received non-steroidal drugs for 2 days before and 4 weeks after cataract surgery did not develop macular edema.² The study has been replicated several times, with similar results.

Dosing recommendations

Dr. Raizman recommended the use of a topical NSAID 1 or 2 days prior to surgery and then for 4 weeks following surgery for routine cases. “The exact dosing schedule has not been well defined, as studies have not addressed this concern,” he explained. “I find that using a non-steroidal agent two times to three times a day for 3 or 4 weeks post surgery is adequate.”

For at-risk patients, Dr. Raizman said he begins the NSAID 1 week preoperatively and continues the regimen for at least 4 weeks to 6 weeks postoperatively. Patients presenting with diabetic retinopathy should receive non-steroidal treatment for at least 8 weeks preoperatively. OCT can serve as a guide for determining the duration of the therapy.

Pre-emptive care

“Endophthalmitis is devastating, but macular edema is common,” said Raizman. “Patients have higher expectations for positive outcomes, especially around cataract surgery, but even more so after refractive lens procedures.” Raizman explained that preoperative dosing should be used to blunt and inhibit the inflammatory response of ocular tissue before it occurs, and postoperative dosing should be extended in high-risk patients. “Non-steroidal drugs are effective,” he concluded. “They reduce angiographic macular edema and can also have a beneficial effect on visual function.”

References

1. O’Brien TP. Emerging guidelines for use of NSAID therapy to optimized cataract surgery patient care. Curr Med Res & Opin. 2005;21;1131-1137.
2. McColgin AZ, Raizman MB. Efficacy of topical diclofenac in reducing the incidence of postoperative cystoid macular edema. Invest Ophthmol Vis Sci. 1999;40:289.