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Steroids still most popular choice in postcataract surgery treatment
Following cataract surgery, the main concerns for the comanaging optometrist are preventing infection and reducing inflammation. While improved surgical techniques and devices have lessened the risk of these complications during follow-up care, practitioners must still address them with postoperative therapeutics. For some patients, the traditional approach of steroids for postoperative pseudophakic inflammation may aggravate other conditions, such as elevating intraocular pressure (IOP). Rather than abandon the most effective weapon in their armamentarium, practitioners recommend supplementing steroids with other medications to reduce IOP without inducing other problems. Many practitioners have also switched from aminoglycosides to fluoroquinolones for postoperative antibiotic therapeusis.
Steroids as first choice
Increased potency and reduced likelihood of side effects make steroids the popular choice for treating inflammation, though doctors interviewed by Primary Care Optometry News differed on their dosing regimens.
Michael M. Bloom, OD, in private practice in Atlanta, recommends Pred Forte (1% prednisolone acetate, Allergan) four times daily for the first week, then tapers to three times daily the second week, twice daily for the third week and daily during the fourth.
Other doctors opt for a longer initial dosage period before beginning to taper the medication. Brett G. Bence, OD, FAAO, director of optometry at TLC Northwest Eye in Seattle, said he uses EconoPred Plus (1% prednisolone acetate, Alcon) four times daily for 3 weeks, then reduces the dosage to twice daily for a week. Lee S. Peplinski, OD, FAAO, with Bennett & Bloom Eye Centers in consultative practice in Louisville, Ky., uses Pred Forte four times daily for 2 weeks, then tapers the dosage. “That is probably more drop therapy than the average practice, with the idea being that the best way to treat cystoid macular edema (CME) is to prevent it,” Dr. Peplinski said.
Avoid IOP increase
The two most frequent side effects for steroid responders in general are cataract formation — which is no longer a concern for patients with IOLs — and IOP increase. Despite this risk, Dr. Bence believes corticosteroids are still an essential component of treatment because they are more effective than nonsteroidal anti-inflammatory agents (NSAIDs).
“Steroids work better to suppress inflammation, so if you encounter a steroid responder, I would rather add a glaucoma drug, such as an aqueous suppressant, than switch to an NSAID or ‘soft steroid’,” Dr. Bence said. “Exceptions exist, though, where extreme pressure spikes necessitate replacing prednisolone acetate.” In patients taking both steroids and aqueous suppressants, Dr. Bence monitors their IOP closely to ensure it remains under control. Many steroid responders will not see much increase in pressure during the first week of treatment equivocally due to either postop aqueous shutdown or enhanced outflow. As inflammation subsides, steroid responders start to spike. At 1 week, the pressure may start to spike, which could require a change in medication.
“At that point, you have to make a choice between going with one of the soft steroids, one of the newer ones such as Alrex (loteprednol etabonate 0.2%, Bausch & Lomb), or going with Vexol (rimexolone, Alcon) or switching to an NSAID. Again, I tend to favor going with an aqueous suppressant such as Iopidine (apraclonidine HCl, Alcon) or Alphagan (brimonidine, Allergan) compared with removing the prednisolone acetate altogether,” Dr. Bence said.
NSAIDs less potent alternative
The clear cornea cataract extraction procedure has greatly diminished the amount of anterior chamber inflammation or iritis, reducing the importance of an anti-inflammatory medication. With less inflammation, practitioners are more comfortable using NSAIDs for patients who are steroid responders or who have conditions that might be aggravated by a steroid, Dr. Peplinski said.
“In today’s small-incision surgery, the amount of inflammation is pretty mild, and a nonsteroidal, such as Acular (ketorolac, Allergan) can handle it,” he said. “If we have someone for whom steroids are contraindicated, someone who has a previous herpes simplex virus infection or someone who is a steroid responder, we go with an NSAID. I think they do a good job, but comparing one to the other, you’d have to say the steroids are a little more potent.”
For patients who have some scratchiness on the ocular surface, Dr. Bloom will prescribe an NSAID to relieve the discomfort, but will prescribe steroids to resolve the inflammatory response.
“I’ve had very good success with prednisolone acetate, and it’s been such an effective agent for such a long time that I stay with that regimen. I have not found too many surgeons who are comfortable with the NSAIDs yet,” he said.
NSAIDs to minimize macular edema
For patients who are at risk for developing macular edema, Dr. Bence prescribes NSAIDs, generally Voltaren (diclofenac, CIBA Vision), in addition to a corticosteroid.
“NSAIDs are effective prostaglandin inhibitors,” he said. “I tend to think NSAIDs are best suited as a prophylactic regimen for these high risk CME patients. Some doctors argue that NSAIDs can help control pain because prostaglandins mediate pain. However for the postsurgical cataract patient, we need to identify what is causing the pain (e.g., uveitis, corneal epithelial defect, increased IOP, retrobulbar hemorrhage) and treat the problem. NSAIDs can assist in modulating corneal pain, but defects are usually temporary and NSAIDs unnecessary.”
Dr. Bence also prescribes NSAIDs with corticosteroids for some difficult surgical cases, such as patients who have suffered a posterior capsular tear with vitreous loss during surgery. If the surgery involves a particularly long phacoemulsification time, the patient may be at a greater risk of pseudophakic anterior uveitis and CME.
“We do not use oral antibiotic prophylaxis with either vitreous loss, wound leak, or any other non-endophthalmitis complication,” he said. “Studies show that there is poor vitreal penetration with oral medications. A study in American Journal of Ophthalmology in May 1998 showed peribulbar injection delivered four times greater vitreous concentration of corticosteroid than oral administration. Direct diffusion through the sclera, probably through perineuronal and perivascular emissary channels, was considered the route of drug transport. If this data is extrapolated empirically, we should consider periocular use before oral use of antibiotics in at-risk patients. Still, our center and most others do not consider oral antibiotics worthwhile in patients with vitreous loss.”
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Fluoroquinolones for infection
The risk of endophthalmitis following surgery has led many practitioners to switch from aminoglycosides to fluoroquinolones. Dr. Bloom prescribes a drop of Ocuflox (ofloxacin, Allergan) four times daily, beginning 3 days before surgery, then continues the same dosage and frequency for 7 days following the surgery.
“The aminoglycosides possess an increased risk of a toxic reaction,” he said. “The fluoroquinolones cover a broader spectrum and show less resistance. When you are dealing with the possibility of endophthalmitis postsurgically, you go with the strongest gun.”
Fluoroquinolones do carry the risk of causing toxic keratitis when prescribed for an extended period following surgery, Dr. Peplinski said. “The biggest risk of endophthalmitis will be present within the first 3 days, so if you are out beyond that window and the wound is healing well, you can discontinue or change treatment if the patient is not tolerating the drug well,” he said.
Endophthalmitis may develop between 3 days and several weeks postoperatively, depending on the virulence of the organism, said Dr. Bence. The precipitous onset involves rapid loss of visual acuity, pain, chemosis, hypopyon, photophobia and vitreous inflammation. Generally, antibiotics should be discontinued after a week when the wound has sealed.
When patients complain that their vision is suddenly worsening or pain is developing 5 days or more after the surgery, they need to be seen that day, Dr. Bence said. “With endophthalmitis, a matter of hours can make a substantial difference on the prognosis,” he said.
For Your Information:
- Michael M. Bloom, OD, can be reached at Ross Eyecare Group, 2625 Piedmont Rd., Atlanta, GA 30324; (404) 233-3513; fax: (404) 814-0184.
- Brett G. Bence, OD, FAAO, can be reached at TLC Northwest Eye, 10330 Meridian Ave. N, Ste. 370, Seattle, WA 98133; (206) 528-6000; fax: (206) 522-1479; e-mail: bgbence@msn.com.
- Lee S. Peplinski, OD, FAAO, can be reached at Bennett & Bloom Eye Centers, 4500 Churchman Ave., Ste. 203, Louisville, KY 40215; (502) 364-0033; fax: (502) 361-4488; admin@eyecenters.com. Drs. Bloom, Bence and Peplinski have no direct financial interest in the products mentioned in this article, nor are they paid consultants for any companies mentioned.