Surgeon makes case for Omidria, bromfenac for cataract surgery care
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Welcome to another edition of CEDARS/ASPENS Debates. CEDARS/ASPENS is a society of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.
This month, Denise M. Visco, MD, MBA, discusses her management of patients after cataract surgery and why topical steroids may not be needed to protect against cystoid macular edema. We hope you enjoy the discussion.
Kenneth A. Beckman, MD, FACS
OSN CEDARS/ASPENS Debates Editor
The most common standard of care for post-cataract surgery patients is a topical nonsteroidal and prednisone combination.
I published a paper in 2020 on replacing the topical steroid with intracameral Omidria (phenylephrine 1% and ketorolac 0.3% intraocular solution, Omeros) and the effect it had on cystoid macular edema (CME), postoperative breakthrough iritis and postoperative pain. We showed that with the combination of intracameral and topical nonsteroidal, the rate of CME decreased threefold. The CME rate in our practice with combined topical steroid/NSAID was about 1.5%, but we were able to lower it to about 0.5% with the substitution of intracameral Omidria for our topical steroid.
Unfortunately, not everyone can get Omidria, so topical prednisone is still widely used. With the approval of drugs such as Dextenza (dexamethasone ophthalmic insert 0.4 mg, Ocular Therapeutix) and Dexycu (dexamethasone intraocular suspension 9%, EyePoint Pharmaceuticals), and the availability of drugs from 503A or 503B pharmacies, I wondered if these applications with intracameral NSAID could be superior to the NSAID combination or, basically, “Can we replace the topical bromfenac and just go dropless?” What my partner and I found, in our retrospective study of approximately 1,000 eyes, was the combination of Omidria and intracanalicular steroid increased our CME rate tenfold to 4%. Any way we have tried to improve on the combination of intracameral Omidria and topical bromfenac has failed. We still need that one drop, and it needs to be an NSAID.
According to our most recent study, starting a nonsteroidal 2 days preoperatively, using a nonsteroidal intracamerally during the surgery and then using the nonsteroidal for 4 weeks postoperatively is the best protocol with the lowest incidence of CME, the lowest incidence of breakthrough iritis and the lowest incidence of pain after surgery. Thus far, it is better for us than anything that combines a steroid at all. You have a continuous application and then flow of the nonsteroidal, which prevents the inflammatory receptors from opening up during surgery. Even though it can be a short period of time for some surgeons, exposure of inflammatory receptors matters. If you are not using Omidria, you will have a higher level of prostaglandin formation occurring as the inhibition of COX-1 and COX-2 receptors wanes during the active cataract procedure. You will establish the task of managing the damage increased prostaglandins cause, as your prevention mode fails.
Throughout the literature, the best CME rate with the standard prednisone-nonsteroidal combination is about 1.5%. You can reduce your clinical CME rate threefold with an NSAID-only combination of Omidria and topical bromfenac, if it is available to you. Although it is easy to see the lure, we need continuous COX-1 and COX-2 suppression intraop and postop cataract surgery. We need NSAIDs and are not yet dropless.
- Reference:
- Visco DM, et al. J Cataract Refract Surg. 2020;doi:10.1097/j.jcrs.0000000000000193.
- For more information:
- Denise M. Visco, MD, MBA, can be reached at Eyes of York, 1880 Kenneth Road, Suite 1, York, PA 17408; email: deniseviscoeyes@gmail.com.
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