Practice patterns for perioperative NSAID use

WAILEA, Hawaii — Should ophthalmologists use topical nonsteroidal anti-inflammatory drugs routinely when performing cataract or lens surgery? Eric Donnenfeld, MD, and John Wittpenn, MD, presented their thoughts on the subject here at an Allergan-sponsored breakfast during the Hawaiian Eye meeting.

A third ophthalmologist, Uday Devgan, MD, FACS, who writes the new OSN Back to Basics column for Ocular Surgery News, provided the following summary of their presentations for the OSN SuperSite. Dr. Devgan will provide additional reports from the meeting in coming days.

Dr. Wittpenn said patients now expect excellent vision immediately after surgery, with no pain or discomfort, no reduction in contrast sensitivity and no complications from the surgery. He suggested that ophthalmologists revise their definition of cystoid macular edema (CME) to include any decrease in visual function as a result of macular thickening. He proposed using ocular coherence tomography rather than Snellen acuity to detect CME, and he said that topical NSAIDs can effectively reduce or prevent CME.

Dr. Wittpenn recommended using NSAIDs in patients undergoing any lens-based surgery, particularly those at higher risk, such as patients with a history of diabetes, vascular occlusion, uveitis, macular pucker, previous ocular surgery or CME in the fellow eye after previous surgery.

He added that with numerous topical ophthalmic NSAIDs available to physicians, corneal melting is “not an issue” as it was briefly in the late 1990s.

Dr. Donnenfeld said the multipurpose topical NSAID is “the cataract surgeon’s best friend,” and its use results in better outcomes and more efficient surgery.

Among the benefits of NSAIDs, he said, are inhibition of intraoperative miosis, reduction of pain during and after surgery when the NSAID is given preoperatively, and easier management of postop inflammation. They also help in the treatment of CME after surgery and can help to prevent intraoperative complications during surgery, Dr. Donnenfeld said.

He presented results from a randomized, double-masked study of 100 patients divided into four groups. Three groups received ketorolac 0.4% before surgery at 3 days, 1 day or 1 hour; all three groups received the NSAID four times daily after surgery for 2 weeks. The fourth group, which received no NSAIDs, served as controls.

The patients who received ketorolac 3 days before surgery had significantly less pupil constriction, a lower mean surgical time, a lower mean ultrasound time, a lower mean effective phaco time, reduced inflammation, improved corneal clarity and improved visual outcomes compared with the other groups, he said.

“NSAIDs as a surgical tool are as vital as the choice of the phaco handpiece or the viscoelastic in improving cataract surgery outcomes,” he said.