“Buffered solutions with higher concentrations of lidocaine can also be used. Anti-inflammatory drugs should be given before surgery. Nonsteroidal antiinflammatory drugs (NSAIDs) have become an important adjunctive tool for surgeons performing routine and complicated cataract surgery. These are given to reduce inflammation after cataract surgery. This is a major cause of postoperative pain,” Farid said. These claims have not been verified by the U.S. Food and Drug Administration. Injectable steroids under the conjunctiva, such as subconjunctival dexamethasone or a sub-Tenon’s injection of triamcinolone, or intracamerally with appropriate medications can result in a better anti-inflammatory response after cataract surgery, according to Devgan. Flare in the anterior chamber was lowest with ketorolac tromethamine (p=0.008) and surface inflammation was lowest with prednisolone (p=0.002). Schacke H, Docke WD, Asadullah K, Mechanisms involved in the side effects of glucocorticoids. Heier JS, Topping TM, Baumann W, et al., Ketorolac versus prednisolone versus combination therapy in the treatment of acute pseudophakic cystoid macular edema. Ophthalmologists generally view visual acuity outcomes as the most important concept in cataract and ophthalmic surgery, but patients perceive pain as equally important, OSN Cornea/External Disease Board Member Eric D. Donnenfeld, MD, said. Corticosteroids are effective, but NSAIDs may provide an additional benefit to reduce inflammation when given in combination with corticosteroids. 11 Compared with NSAIDs, corticosteroids have a wider range of activity in relieving inflammation (see Figure 1 ). Antibiotic eyedrops are used after cataract surgery to prevent infection and steroid and NSAID (non-steroidal anti-inflammatory drug) eyedrops are used to reduce and remove inflammation. Nepafenac ophthalmic suspension is used to reduce pain and swelling after cataract surgery. Your eyes are tested one at a time, while the other eye is covered. A review of studies published in the last 10 years indicates that C-20 ester corticosteroids provide effective control of post-cataract surgery inflammation without the elevation of IOP. This easily placed slow-release medication with minimal potential of side effects has the potential to significantly change our postoperative medication landscape,” she said. The two main classifications of medications surgeons use to control postoperative pain and inflammation are NSAIDs for reducing pain and steroids for reducing postoperative inflammation. This article was funded by Bausch & Lomb. The rapid metabolism of LE results in a lower propensity to induce IOP elevation compared with C-20 ketone corticosteroids, even when administered to known corticosteroid responders.38 LE has been shown to be a safe corticosteroid when used to treat a number of ocular inflammatory conditions, including giant papillary conjunctivitis, seasonal allergic conjunctivitis, uveitis, dysfunctional tear syndrome and post-cataract surgery inflammation.20,21,27,38–45 Hsu JK, Johnston WT, Read RW, et al. The nanoparticle formulation is delivered via Kala’s mucus-penetrating technology. Aside from medication, patient comfort is also a factor in pain and inflammation associated with cataract surgery, OSN Refractive Surgery Board Member Jason P. Brinton, MD, said. (Click Prolensa Usesfor more information on … Loteprednol etabonate ophthalmic suspension 0.5 % is the only topical C-20 ester corticosteroid approved for use in the treatment of corticosteroid-responsive inflammatory conditions including post-operative ocular inflammation. Lotemax, Alrex and Durezol are relatively newer and more expensive. She graduated in pharmacology and statistics (MSc) and completed her PhD thesis in anatomy. The assessment of cells did not differ among the treatments (p=0.165). Bromfenac and nepafenac are both excellent NSAIDs. Dexycu (dexamethasone intraocular suspension) 9% is an extended-release steroid that replaces eye drops after cataract surgery with a single shot. “[It] will be an excellent corticosteroid for cataract surgery and dry eye.”. World Health Organization, World Health Bulletin on Priority eye diseases: Main causes of visual impairment. Floaters appeared after having cataract surgery. However extended use requires careful monitoring and reporting. ■. “I also use femtosecond laser cataract surgery. Loteprednol etabonate, C-20 ester corticosteroids, non-steroidal anti-inflammatory drugs, ocular inflammation, cataract surgery. Not all patient populations are the same, not all cataracts are the same, and not all surgeons have the same experience. Pavesio CE, Decory HH, Treatment of ocular inflammatory conditions with loteprednol etabonate. Dextenza could possibly lead to less reliance on postoperative anti-inflammatory drops, Farid said. European Ophthalmic Review. Younger patients and highly myopic patients can be more sensitive to changes in anterior chamber fluid volume and IOP. Henderson B, Kim J, Ament C, et al., Clinical pseudophakic cystoid macular edema- Risk factors for development and duration after treatment. Cataract surgery is a procedure to remove the lens of your eye and, in most cases, replace it with an artificial lens. Cataract surgery is very common and is generally a safe procedure. Prostaglandins are released naturally from the iris and ciliary body and migrate to the retina after cataract surgery.14 The inflammatory response may lead to the activation of the immune cascade, involving neutrophils, macrophages, T lymphocytes and additional inflammatory mediators.11,14,15 Post-cataract surgery inflammation presents as protein flare and inflammatory cells in the anterior chamber, hyperaemia, miosis, oedema, leukocyte migration, fibroblast proliferation and scar formation, along with other local responses to the released pro-inflammatory cytokines.16,17 Persistent inflammation leads to higher rates of post-operative cystoid macular oedema (CMO), patient discomfort and compromised visual outcomes12,13,17 consequent to the breakdown of the blood–retinal barrier.18 Multiple potential complications of untreated post-operative inflammation include pain, photophobia, posterior synechiae, pseudophakic cellular precipitates, uveitis, elevated intraocular pressure (IOP) and glaucoma.6 – by Robert Linnehan. None of the patients in the group receiving peri-operative diclofenac developed CMO compared with 12 % of the patients in the group receiving post-operative treatment only.65 The use of the miLOOP (IanTECH/Zeiss) for a more dense cataract can help break the cataract into smaller pieces intraocularly and make it easier to remove. In two similar clinical trials evaluating the use of LE for treating post-cataract inflammation, LE produced significantly lower rates of treatment-emergent adverse events compared with placebo (p<0.001 in study 1 and p=0.002 in study 2).20,21 There was no significant difference in mean change in IOP with LE compared with placebo and no evidence of deleterious effects on post-operative recovery.20,21 LE had a smaller impact on IOP increase than prednisolone acetate when these corticosteroids were compared in patients undergoing cataract surgery.46 Long-term (≥28 days) administration of either LE 0.2 or 0.5 % was associated with a low incidence of elevated IOP, which was comparable with placebo and lower than the rate observed with prednisolone acetate 1.0 %.47 LE (0.2 %) has reportedly been used for up to three years in patients with allergic conjunctivitis without inducing clinically significant elevated IOP (p=0.824).44, Post-operative corticosteroid treatment results in a reduced presence of inflammatory cells and flare within the anterior chamber compared with placebo.22–25 In the above clinical trials, LE was more effective than placebo in reducing anterior chamber cells and flare when used after cataract surgery in patients with a cumulative inflammation severity of at least grade 3 (on a scale of 0–9).20,21 A significantly greater proportion of LE-treated patients versus patients taking placebo achieved complete resolution of anterior chamber cells and flare (p<0.001 for both studies).20,21 By the final visit, 93 and 89 % of LE-treated patients compared with 65 and 64 % of vehicle-treated patients, respectively, had mild or resolved anterior chamber inflammation in each study.20,21 Reduction in severity for both cells and flare individually, on average, was greater in the LE group compared with the placebo group (see Figures 3 and 4; p<0.001 for both end points in both studies).20,21 There was no indication of rebound inflammation following the cessation of LE therapy. You may use these drops for just a few days, or your doctor might ask you to use them for a month or so. Ketorolac ophthalmic is also used to reduce swelling, pain, and burning or stinging after cataract surgery or corneal refractive surgery. You know your patient and your population, your nuances, better than everyone else. The production of prostaglandins should be prevented, as agents that can neutralize their action following their release are not available. Topical anti-inflammatory agents are routinely used after cataract surgery to control post-operative inflammation. Loteprednol Allergic Conjunctivitis Study Group. There are many options here, some more expensive than others. A double-masked, placebo-controlled evaluation of 0.5% loteprednol etabonate in the treatment of postoperative inflammation. Pre- and postop topical steroids reduce inflammation and are helpful at reducing corneal swelling. Solomon KD, Vroman DT, Barker D, Gehlken J, Comparison of ketorolac tromethamine 0.5% and rimexolone 1% to control inflammation after cataract extraction. Even though NSAIDs work by inhibiting prostaglandin production, they do not influence preformed prostaglandin, according to Donnenfeld. While corticosteroids are traditionally the therapy of choice for inflammation, their long-term use for managing ocular inflammation can produce significant adverse events. Cantrill HL, Palmberg PF, Zink HA, et al., Comparison of in vitro potency of corticosteroids with ability to raise intraocular pressure. Available at: www.rcophth.ac.uk/documents.asp?section=39& sectionTitle=Publications&page=9 (accessed 4 April 2012). After a couple of days, most of the discomfort should disappear. The FDA approved Dextenza (dexamethasone ophthalmic insert 0.4 mg, Ocular Therapeutix), the first intracanalicular insert to deliver dexamethasone to treat postoperative ocular pain for up to 30 days, in December. This also greatly reduces the energy being put into the eye and offers the potential for less corneal edema, Trattler said. NSAIDs are cyclo-oxygenase inhibitors that work by suppressing production of prostaglandins. Drug delivery systems are the future of pharmaceuticals in ophthalmology,” he said. A 2016 review by Hoffman and colleagues groups the commercially available NSAIDs into six major classifications: salicylates, fenamates, indoles, phenylalkanoic acids, phenylacetic acids and pyrazolones. Laurell CG, Zetterstrom C, Effects of dexamethasone, diclofenac, or placebo on the inflammatory response after cataract surgery. Introduction: Bromfenac is a topical ophthalmic non-steroidal anti-inflammatory drug (NSAID) used to reduce pain and treat post-operative inflammation after cataract surgery. The intraoperative, intracameral delivery of dexamethasone in the eye should provide “extremely high levels of anti-inflammatory therapies” and will absorb over 2 to 3 weeks, he said. We begin with an insightful Expert Interview with Deborah K VanderVeen, from Boston Children’s Hospital, about the rationale for the use of orthokeratology for the […], US Ophthalmic Review. Healio.com. The more phaco energy you put in the eye, the more inflammation you’ll have postop. Patients also have quieter eyes, which I believe is due to the intracameral use of the ketorolac.”. Important information Dextenza demonstrated efficacy in two randomized, vehicle-controlled phase 3 studies in which a statistically significant number of patients who received the insert were free of pain 8 days after cataract surgery compared with patients in the vehicle control group. What works well in my hands in a Beverly Hills setting may not work the same, even if it’s my own hand, in this underserved part of Los Angeles at our county teaching hospital. Jonas JB, Kreissig I, Spandau UH, Harder B, Infectious and noninfectious endophthalmitis after intravitreal high-dosage triamcinolone acetonide. In the charity clinic with my UCLA residents, this is the home of the brunescent and white cataract. Cataract surgery is very common and is generally a safe procedure. Solomon R, Donnenfeld ED, Recent advances and future frontiers in treating age-related cataracts. obtained serial 100 μl samples of aqueous humor in 12 patients undergoing cataract surgery. The three most typical postoperative classes of medication — antibiotic, steroid and NSAID — can cost more than the surgeon’s fee for cataract surgery if they are the retail brand name medications, Devgan said. DeCroos FC, Afshari NA, Perioperative antibiotics and anti-inflammatory agents in cataract surgery. Stern GA, Factors affecting the efficacy of antibiotics in the treatment of experimental postoperative endophthalmitis. O'Brien TP, Emerging guidelines for use of NSAID therapy to optimize cataract surgery patient care. “A Beverly Hills cataract is removed pretty easily because the modest nuclear sclerosis means that it’s not dense. Visual acuity test. El-Harazi SM, Feldman RM, Control of intra-ocular inflammation associated with cataract surgery. When administered together, NSAID plus corticosteroid therapy was more effective for mean decrease in corneal inflammatory activity in rabbits than treatment with either drug alone, regardless of whether therapy was initiated before or after the inflammatory event.66 Anti-Infective Agents. Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used in cataract surgery and may reduce the chances of developing MO. Mati Therapeutics announced interim phase 2 clinical trial results evaluating the efficacy of nepafenac delivered via sustained ocular drug delivery platform. “Cataract surgeons will be very happy with the approval of Dextenza for the treatment of postoperative pain. When beginning the procedure, the surgeon must respect the corneal epithelium and not inadvertently cause a corneal epithelium abrasion. Inveltys was FDA approved in 2018 and is the only twice-daily corticosteroid for the treatment of postoperative inflammation and pain after ocular surgery. It reduces pain and inflammation in the eyes. Rowen S, Preoperative and postoperative medications used for cataract surgery. Strategies for treatment and removal need to be carefully considered, he said. Both drugs were well tolerated but conjunctival hyperaemia was less pronounced in the dexamethasone group on post-operative day 30 (p=0.046). A patient who is familiar with the operating environment, the surgeon and the clinic staff can be more at ease during a procedure and experience less discomfort postoperatively, Brinton said. Although all the active agents were more effective than placebo in controlling inflammation, used together these drugs may work synergistically to offer more effective control of inflammation and prevention of CMO. Holzer MP, Solomon KD, Sandoval HP, Vroman DT, Comparison of ketorolac tromethamine 0.5 % and loteprednol etabonate 0.5 % for inflammation after phacoemulsification: prospective randomized double-masked study. 2020;13(1):16–7 DOI: https://doi.org/10.17925/USOR.2020.13.1.16, I was interested to read the review, “Optical Lens Tinting—A Review of its Functional Mechanism, Efficacy, and Applications” by Jared Raabe, Ashwini Kini, and Andrew Lee, which appeared in US Ophthalmic Review.1 I am the inventor of the FL–41 lens that features in the article. While corticosteroids have a broader mechanism of action – inhibiting both the cyclo-oxygenase and lipoxygenase pathways through inhibition of phospholipase A2 – traditional corticosteroids are limited in that they lead to elevated IOP. Non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids are used to prevent and reduce inflammation following cataract surgery, but these two drug classes work by different mechanisms. The Study Group. Leibowitz H, Ryan W, Kupferman A, DeSantis L, Effect of concurrent topical corticosteroid and NSAID therapy of experimental keratitis. Cataract surgery usually goes well, but it helps to know what to look out for. In a recent review, bromfenac twice daily (BID) was found to demonstrate an early and sustained level of clinical activity with little burning and stinging and minimal adverse events in the treatment of ocular inflammation following cataract surgery.56 Preclinical studies with bromfenac demonstrated that the addition of bromine increased ocular penetration, suggesting that bromfenac BID may be as potent as other NSAIDs administered more frequently but with less potential for corneal toxicity. Antibiotic eyedrops are used after cataract surgery to prevent infection and steroid and NSAID (non-steroidal anti-inflammatory drug) eyedrops are used to reduce and eliminate inflammation. There are a variety of topical steroids available, and each has its own benefits. Tell us what you think about That’s another drug coming down the line, a punctal plug NSAID drug delivery. Lotemax gel, a topical corticosteroid, was FDA approved in 2012 for the treatment of postoperative inflammation and pain after ocular surgery. CBD is short for cannabidiol, a chemical from the hemp plant that has become increasingly popular in recent years because it has no intoxicating effects. In a retrospective chart review of 450 consecutive patients who had uncomplicated cataract surgery, those patients treated with prednisolone alone had a higher incidence of visually significant macular oedema as documented by optical coherence tomography (OCT) compared with those treated with both prednisolone and nepafenac (five patients versus no patients, respectively, p=0.0354).63 In a clinical trial investigating the use of ketorolac (0.4 %) in combination with prednisolone acetate (1 %), a notably reduced mean retinal thickening was observed through OCT in patients receiving combination therapy compared with patients receiving only prednisolone acetate (3.9 versus 9.6 μm, p=0.003).64 No patients in the combination group and five patients in the prednisolone group developed clinically apparent CMO (p=0.032). One patient receiving ketorolac tromethamine developed corneal erosion. Flach AJ, Cyclo-oxygenase inhibitors in ophthalmology. The usual frequency is … Disclosures: Brinton reports he is a consultant for STAAR Surgical, Johnson & Johnson, Nidek and Zeiss. If patients associate pain with the procedure, they may be left with negative feelings about the practice, no matter how much their vision improves. Treatment with peri-operative ketorolac and post-operative prednisolone acetate significantly reduced the incidence of both CMO and macular thickening in cataract surgery patients, indicating that the combination of a corticosteroid and an NSAID was synergistic in the prevention of inflammation following surgery.64 Similarly, treatment with diclofenac for two days pre-operatively and four weeks post-operatively plus steroid post-operatively reduced the incidence of CMO in a study of 60 patients undergoing small-incision cataract surgery as compared with treatment with diclofenac and steroid post-operatively only. BromSite was approved by the FDA in 2016 to prevent pain and treat inflammation in cataract surgery and is delivered via the DuraSite vehicle, which is a polymer-based formulation that increases the drug’s residence time on the ocular surface. As well, its intraoperative use aids with postoperative inflammation. In a separate 2011 study in the American Journal of Ophthalmology, patients treated with Durezol experienced less corneal edema than those treated with prednisolone acetate. Dextenza’s approval is another positive addition to a surgeon’s armamentarium to limit pain and inflammation after cataract surgery. Using a chart or a viewing device with progressively smaller letters, your eye d… In contrast, corticosteroid therapy (prednisolone acetate) was markedly effective, both when used after the induction of inflammation and when initiated 48 hours previously. Colin J, The role of NSAIDs in the management of postoperative ophthalmic inflammation. Cataract surgery is a procedure to remove the lens of your eye and, in most cases, replace it with an artificial lens. 6. The more fluid you run through the eye, the more inflammation you’ll have postop. Raizman M, Donnenfeld E, Weinstein A, Clinical comparison of two topical prednisolone acetate 1% formulations in reducing inflammation after cataract surgery. Bromfenac became available in the EU in 2011. Normally, the lens of your eye is clear. Cho H, Wolf K, Wolf E, Management of ocular inflammation and pain following cataract surgery: focus on bromfenac ophthalmic solution. Therefore, pretreatment with an NSAID is an important step in a surgeon’s protocol to limit postoperative pain. What is used after cataract surgery to reduce inflammation? Also, microscopic remnants of the cataract are often left in the anterior chamber of the eye, which lead to continued release of inflammatory factors. The efficacy of indomethacin 0.1 % was compared with that of dexamethasone 0.1 % in a randomised double-masked study of 145 patients undergoing cataract surgery.60 Protein flare and cells decreased in both groups, with a difference in favour of indomethacin for cells at post-operative day 30 (p=0.046). McGolgin AZ, Raizman MB, Efficacy of topical Voltaren in reducing the incidence of postoperative cystoid macular edema. The authors have no conflicts of interest to declare. The role of NSAIDs in the management of postoperative ophthalmic inflammation. Durezol are relatively newer and more expensive makes you wonder, is there a cheaper, way... With postoperative inflammation antibiotics in the eye it makes you wonder, is a. Pavesio CE, Decory HH, treatment of ocular pain following cataract surgery: a global and analysis... 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