Perioperative medications can be beneficial in cataract surgery

Topical medications before and after surgery can help modulate healing, decrease scarring and even improve visual recovery.

Issue: November 25, 2010

ByUday Devgan, MD

Uday Devgan

As surgeons, we know that good surgical technique is important in achieving good visual results from cataract surgery. However, equally important is the patient’s healing response and progress after surgery and avoiding complications that may result in suboptimal vision. Using topical medications before and after surgery can help modulate healing, decrease scarring and even improve visual recovery after phacoemulsification.

The three primary classes of medications used around the time of cataract surgery are antibiotics, corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs). Within these classes, there are multiple medications from which to choose, including generics. Among the factors that may help surgeons select medications are penetration; potency; dosing regimen, which will affect compliance; and clinical efficacy.

Antibiotics

We use perioperative antibiotics in an effort to prevent endophthalmitis, a rare but devastating complication after cataract surgery. The idea is that dosing the antibiotic before and after surgery largely eliminates the bacterial flora of the ocular surface and kills any intraocular bacteria, which will hopefully result in a lower incidence of endophthalmitis. There is no prospective, randomized trial showing the efficacy of topical antibiotics in the prevention of endophthalmitis. The ESCRS endophthalmitis study concludes that intracameral cefuroxime at the time of surgery may reduce the risk of endophthalmitis.

The mainstays of topical antibiotics in the perioperative period are the fluoroquinolones, which are indicated for the treatment of bacterial conjunctivitis but are routinely used off-label. The fluoroquinolones have a wide spectrum of coverage and good penetration into ocular tissues, and multiple different antibiotics in this class are available in both branded and generic forms. They are often administered a few days before surgery and then continued for 1 week to 2 weeks after surgery, when the risk of infection is greatest. Perhaps even more important than topical antibiotics is using povidone iodine solutions to disinfect the ocular surface and eyelids prior to surgery.

Corticosteroids

The inflammatory response after cataract surgery can be pronounced due to the surgical trauma and also from the release of lens proteins, resulting in a red, painful eye. In addition, the capsular bag contracts and may fibrose after implantation of the IOL. This inflammation, fibrosis and pain can be reduced and the healing response modulated by using corticosteroids.

There are multiple steroids available: ketone steroids such as Pred Forte (prednisolone acetate 1%, Allergan), halogenated steroids such as Durezol (difluprednate ophthalmic emulsion 0.05%, Alcon) and ester steroids such as Lotemax (loteprednol etabonate ophthalmic suspension 0.5%, Bausch + Lomb). The ketone steroids are readily available in generic form, the halogenated steroids are stronger, and the ester steroids have less tendency to cause steroid-induced IOP rises. Dosing is typically for a few weeks after surgery, with the steroids tapered over time to avoid rebound inflammation upon abrupt discontinuation. Because all steroids can induce an increase in IOP, it is important to monitor patients closely during the postop period.

This patient underwent routine cataract surgery with preoperative dosing of bromfenac ophthalmic solution 0.09% to control the inflammatory response. Due to a history of steroid-response glaucoma, the patient’s inflammation was controlled using the NSAID as the sole medication. The day after surgery the patient has a quiet eye with a minimal amount of inflammation and no pain. The green arrow shows the mirror-like reflection of the camera light on the tear film, indicating a good ocular surface.

This patient had cataract surgery by a junior resident physician that was complicated by vitreous prolapse through the pupil (blue arrow) and corneal edema (red arrow). The patient is at a higher risk of postoperative cystoid macular edema, often due to vitreomacular traction, and will require a longer dose of both corticosteroids and NSAIDs and perhaps further intervention.

Images: Devgan U

Nonsteroidal anti-inflammatory drugs

NSAIDs are anti-inflammatory but act at a different site along the arachidonic acid pathway than steroids. The NSAIDs inhibit the cyclo-oxygenase enzymes and may have a synergistic effect if used concomitantly with steroids. The NSAIDs are potent relievers of postoperative pain and are therefore comforting to patients. An additional benefit may be the prevention of postoperative cystoid macular edema, or CME, which can even occur in otherwise uncomplicated surgeries. In order to blunt the postoperative inflammatory response, NSAIDs are frequently given before surgery as well as for a few weeks after surgery. With more complicated surgery or in those eyes receiving presbyopia-correcting IOLs, NSAIDs are often given for a prolonged period of weeks to months.

Patients with retinal issues, particular macular pathologies or a history of uveitis, are more prone to CME in the postop period and may require longer courses of NSAIDs. The same applies to patients who have intraoperative complications such as iris prolapse, ruptured posterior capsules or vitreous loss. Patients receiving multifocal IOLs may be particularly aware of even trace amounts of CME from the decrease in contrast sensitivity due to the mechanism of action of these IOLs. Accommodating IOLs are more sensitive to capsular bag contraction and fibrosis, and a longer course of NSAIDs may be beneficial in modulating this healing response. In the U.S., generic NSAIDs such as flurbiprofen, diclofenac and ketorolac are available and are all dosed four times per day. Because patient compliance improves with fewer doses per day, there may be a benefit to using Nevanac (nepafenac ophthalmic suspension 0.1%, Alcon) three times per day, Acuvail (preservative-free ketorolac tromethamine ophthalmic solution 0.45%, Allergan) two times per day or Bromday (bromfenac ophthalmic solution 0.09%, Ista Pharmaceuticals), which is dosed just once per day.

The results of cataract surgery depend on the surgeon’s technique as well as the patient’s healing in the postoperative period. By using antibiotics to stave off infection, corticosteroids to modulate healing and NSAIDs to quell inflammation, we can ensure optimal visual outcomes for our cataract surgery patients.

Uday Devgan, MD, FACS, FRCS (Glasg), is in private practice at Devgan Eye Surgery in Los Angeles, Beverly Hills and Newport Beach, Calif. He is also chief of ophthalmology at Olive View UCLA Medical Center and associate clinical professor at the UCLA School of Medicine. He can be reached at 11600 Wilshire Blvd., Suite 200, Los Angeles, CA 90025; 800-337-1969; fax 310-388-3028; e-mail: devgan@gmail.com; website: www.devganeye.com. Dr. Devgan has received speaking fees from Alcon, Allergan, Bausch + Lomb and Ista Pharmaceuticals.