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Topical steroid, NSAID, antibiotic an ideal therapy before cataract surgery
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Topical steroids have been used to control inflammation after cataract surgery with lens implantation since the time of Sir Harold Ridley. Ridley noted more inflammation with his early lens implants than that associated with cataract surgery alone. The standard for cataract surgery alone in the late 1940s and early 1950s was the use of a cycloplegic agent, usually topical atropine, after cataract surgery. Ridley, amazingly ahead of his time in so many ways, added intracameral cortisone to his regimen when performing extracapsular cataract extraction with implantation of an acrylic posterior chamber lens, starting in 1950.
While studies using no anti- inflammatory therapy as a control group have shown repeatedly that modern cataract surgery patients will heal with no topical steroid or NSAID use, the patients suffer significantly greater postoperative discomfort, redness and inflammation, with some requiring rescue medications to heal. As noted in the associated round table in this issue of Ocular Surgery News, steroids and NSAIDs, while independently effective in reducing the pain and inflammation associated with cataract surgery, are synergistic in effect, and the majority of cataract surgeons, now more than 80% in the U.S., use them both. This is my personal preference. There is accumulating evidence that both are best given before surgery. This adds no additional cost and yields measurable benefits. In particular, pupillary dilation is better maintained during surgery, making surgery safer. In addition, early postoperative pain is reduced, and corneas are clearer with less inflammation on day 1.
I find that starting an antibiotic steroid 1 week preoperative is excellent for ocular surface preparation, along with lid hygiene and artificial tears. Meibomian gland dysfunction is nearly always present in the preoperative senior patient and usually improves significantly with this therapy. If there is any risk factor for cystoid macular edema, I start the NSAID 1 week preoperative as well, and I am considering doing this routinely. The more recently approved NSAIDs give excellent therapeutic efficacy with once-a-day dosing, and a new intracameral NSAID combined with epinephrine is nearing commercialization.
As exciting as these advances are, many of my patients in Minnesota find their prescriptions being converted to older generic brands. While effective, these four-time-a-day NSAIDs require more careful vigilance for ocular surface irritation and side effects such as punctate epithelial keratopathy and corneal melting. We also have newer, more potent topical steroids that require only once- or twice-daily dosing. Again, in Minnesota, they are commonly substituted by our pharmacists for an earlier-generation topical steroid requiring more frequent dosing. In select cases in which I think it important for my patients to take the actual drugs I prescribe, I so inform them. This remains for me one of the more frustrating aspects of modern-day practice, but the forces favoring generic drugs, the government, third-party payers, and incented pharmacies and pharmacists present what appears to be an insurmountable barrier to change.
I encourage my colleagues to consider preoperative therapy with a topical steroid, NSAID and antibiotic. My clinical experience strongly supports this approach, and independent studies are confirming its efficacy.