Report: NSAIDs do not prevent long-term vision loss from CME after cataract surgery

Contrary to popular belief, NSAIDs and corticosteroids do not act synergistically in reducing long-term risk.

Issue: September 25, 2015

There is insufficient evidence that prophylactic NSAIDs alone or in conjunction with corticosteroids reduce vision loss from cystoid macular edema 3 months or more after cataract surgery, according to an American Academy of Ophthalmology report.

CME often resolves spontaneously. Although NSAIDs before surgery may speed visual recovery and reduce the incidence of CME in the short term, there is no evidence that they affect long-term visual outcomes, the report authors said.

“It has become almost common practice, even standard of care, for cataract surgeons to routinely place [patients], regardless of their risk factors, on a topical nonsteroidal in addition to a corticosteroid,” Stephen J. Kim, MD, the lead author, told Ocular Surgery News. “They’re not using the nonsteroidal to replace a corticosteroid, but they’re using it in conjunction.”

Kim said the cost of administering NSAIDs in conjunction with corticosteroids to the approximately 3 million patients who undergo cataract surgery in the U.S. annually is high.

“From a societal cost, if you look at the brand-name NSAIDs, it’s about $200 a bottle. The cost of routine NSAID use approaches $700 million a year, all for something that is not proven to favorably affect final outcomes,” Kim said.

The Ophthalmic Technology Assessment, written by the AAO’s Ophthalmic Technology Assessment Committee Retina/Vitreous Panel, was published in Ophthalmology.

Kim and co-authors searched the PubMed and Cochrane Library databases, retrieved 149 unique citations, reviewed the abstracts and selected 27 articles to review the full text for possible clinical relevance. Of the 27 articles, 12 were deemed relevant to analyze in their entirety. Two additional articles were identified from the reference lists of the selected articles, and another article was identified from a national meeting.

No symbiotic relationship

Kim and colleagues reported that the published literature does not support the belief that NSAIDs and corticosteroids act synergistically.

“Essentially, when we reviewed all of the literature, we found no evidence that these drugs are synergistic. They may be additive, in which case one drug could be dosed sufficiently enough to replicate the effects of both drugs. They don’t add a unique therapeutic advantage. They’re sort of redundant,” Kim said. “If [physicians] are worried about not putting someone on an NSAID, they can just increase the dosing of the corticosteroid. So, instead of four times a day, they can use a corticosteroid six or eight times a day. From our analysis, that practice may have similar efficacy with less cost.”

Studies that assess the therapeutic effect of NSAIDs should be controlled, focus mainly on longer-term visual outcomes, and involve rigorous assessment of best corrected visual acuity using standardized ETDRS acuity charts, the authors said.

Side effects and risks

Unlike NSAIDs, corticosteroids are associated with elevated IOP after cataract surgery. However, IOP spikes are generally mild and temporary.

“Most IOP spikes are going to be minimal and manageable in the short period of time that a corticosteroid is applied,” Kim said.

Kim and colleagues noted that while CME is more prevalent among patients with diabetes and uveitis, NSAID therapy is still not proven to reduce the long-term risk of CME in those higher-risk patients, he said.

“I’m not sure if there’s any group that I necessarily would recommend using NSAIDs in conjunction with corticosteroids. There’s no evidence to support that. But I would acknowledge that there is definitely a subgroup of eyes that are at higher risk for CME after cataract surgery and may need more prophylaxis and monitoring than eyes that are low risk,” Kim said.

Kim said visually insignificant CME may be overdiagnosed with OCT.

“There may be a perception that mild thickening is detrimental, but in many cases, mild thickening is not visually important and has no long-term consequences,” Kim said. “I think the ease of imaging and the noninvasiveness of OCT have led to the overdiagnosis of clinically important cystoid macular edema. You’re detecting it more often now, but patients are still seeing 20/25 because it is mild. Their vision is not really affected by it, and it is likely to resolve spontaneously.”

Standardized reporting of CME based on OCT findings may allow for more uniform assessment of the incidence of CME and more reliable assessment of treatment outcomes, the report said. – by Matt Hasson

Reference:
Kim SJ, et al. Ophthalmology. 2015;doi:10.1016/j.ophtha.2015.05.014.

For more information:
Stephen J. Kim, MD, can be reached at Vanderbilt Eye Institute, 2311 Pierce Ave., Nashville, TN 37232; email: stephen.j.kim@vanderbilt.edu.

Disclosure: Kim reports no relevant financial disclosures.