A multicenter randomized controlled fellow eye trial of pulse-dosed difluprednate 0.05% versus prednisolone acetate 1% in cataract surgery

Using 2% PVPI topical solution for serial intravitreous injections and ocular surface findings: a case control study

BACKGROUND

The use of povidone-iodine for ocular surface asepsis is widespread for intravitreal injections. They became frequent procedures, leading to serial exposure of patients' eyes to iodinated solutions. In this study, we investigate the changes in the ocular surface in patients submitted to repeated use of povidine for intravitreal injection of anti-VEGF asepsis, analyzing Ocular Surface Disease Index, non-invasive break up time, blinking quality, lipid layer, meniscus height and osmolarity.

METHODS

This case-control study included 34 individuals (68 eyes), 14 males, 20 females aged 48 to 94. Inclusion criteria were individuals who received application of 2% povidone-iodine eyedrops for intravitreal injections treatment with the non-treated contralateral eye used as control. Ocular surface examinations were performed at a single occasion. A pre-intravitreal injection asepsis protocol with povidone-iodine was applied. All statistical analysis was performed using the STATA® 18.0 Software and a p-value = 0.05 was considered as the statistical significance value in all tests.

RESULTS

The median number of IVIs in treated eyes was 12 (range 6-20). The results in treated eyes compared with untreated eyes were respectively : median OSDI 16 (IQR 6-39) and 12.5 (IQR 8-39) (p = 0.380); mean NIBUT 10.30 (SD ± 2.62) and 10.78 (SD ± 2.92) ( s, p = 0.476); median blinking quality 100 (IQR 100) and 100 (IQR 100 ) (%, p = 0.188); median lipid layer 87 (IQR 77-90) and 86 (IQR 74-100) (nm, p = 0.451); median meniscus height 0.22 (IQR 0.19-0,31) and 0.24 (IQR 0.20-0.27) (mm, p = 0.862), median Meibomian gland atrophy 33 (IQR 24-45) and 31.5 (IQR 25-39) (%, p = 0.524); and mean osmolarity 306.6 (SD ± 21.13) and 313.8 (SD ± 29) (mOsm, p = 0.297). There was no statistically significant relationship between the repetitive use of 2% iodinated solution and signs or symptoms compatible with dry eye syndrome in this group of patients.

CONCLUSIONS

The findings suggest that 2% povidone iodine is a safe and efficacious agent for ocular surface antisepsis during intravitreal injections, not leading to substantial ocular surface modifications. This conclusion supports the continued use of povidone iodine in routine ophthalmic procedures without increased risk of inducing dry eye syndrome.

Corneal Edema after Cataract Surgery

This systematic review investigates the prevalence and underlying causes of corneal edema following cataract surgery employing manual phacoemulsification. A comprehensive search encompassing databases such as PubMed, Embase, ProQuest, Cochrane Library, and Scopus was conducted, focusing on variables encompassing cataract surgery and corneal edema. Two independent reviewers systematically extracted pertinent data from 103 articles, consisting of 62 theoretical studies and 41 clinical trials. These studies delved into various aspects related to corneal edema after cataract surgery, including endothelial cell loss, pachymetry measurements, visual performance, surgical techniques, supplies, medications, and assessments of endothelial and epithelial barriers. This review, encompassing an extensive analysis of 3060 records, revealed significant correlations between corneal edema and endothelial cell loss during phacoemulsification surgery. Factors such as patient age, cataract grade, and mechanical stress were identified as contributors to endothelial cell loss. Furthermore, pachymetry and optical coherence tomography emerged as valuable diagnostic tools for assessing corneal edema. In conclusion, this systematic review underscores the link between corneal edema and endothelial cell loss in manual phacoemulsification cataract surgery. It highlights the relevance of factors like patient demographics and diagnostic modalities. However, further research is essential to unravel the complexities of refractive changes and the underlying mechanisms.

2021 Survey of Keratoplasty Postoperative Steroid Management

PURPOSE

The aim of the study is to investigate US-based ophthalmologists' preferred corneal transplant techniques and postoperative steroid regimen.

METHODS

Ophthalmologists attending the 2021 Cornea and Eye Banking Forum and/or Cornea Subspecialty Day were surveyed in person.

RESULTS

Ninety-two ophthalmologists with a median of 13 years (range of 1-35; mean of 14.5; ±9.05 mean ± SD) of experience as attending clinicians were surveyed. One hundred percent of the surgeons performed penetrating keratoplasty, which was followed by 96.7% for Descemet stripping endothelial keratoplasty, 90.2% for Descemet membrane endothelial keratoplasty, and 72.8% for deep anterior lamellar keratoplasty. Prednisolone 1% for postoperative care was the preferred choice across all surveyed keratoplasty techniques and postsurgery time intervals. All surgeons reported steroid administration frequency of 4 times a day in the first month and once a day after 12 months postkeratoplasty. To manage ocular hypertension after corneal transplantation, the leading approach was adding a glaucoma medication (44.6%), and beta-adrenergic antagonists were ranked as the most preferred choice by 59 (66.3%) of the respondents. For graft rejection after corneal transplantation, topical steroids (79.8%) were the initial treatment of choice with hourly administration being the most common frequency prescribed (87.4%). Most surgeons either agreed or strongly agreed (78.4%) that a randomized clinical trial evaluating the safety and efficacy of different steroid regimens after corneal transplantation would influence their clinical decision making.

CONCLUSIONS

Prednisolone remains the predominantly used steroid across different keratoplasties. Steroid regimens are similar for non-high-risk penetrating keratoplasty, Descemet membrane endothelial keratoplasty, Descemet stripping endothelial keratoplasty, and deep anterior lamellar keratoplasty. To treat graft rejection, surgeons tend to initially add a glaucoma medication than to reduce the potency or frequency of the steroid.

Steroid Response Following Dropless Cataract Surgery Using Subconjunctival Triamcinolone

Purpose

To assess the rates of postoperative steroid response following dropless cataract surgery using a subconjunctival depot of triamcinolone versus conventional cataract surgery using topical prednisolone.

Patients and Methods

We reviewed consecutive cataract surgery cases performed by a single surgeon to determine the likelihood of steroid response, defined as intraocular pressure (IOP) 50% above baseline or IOP > 24 mmHg postoperatively, excluding the first 72 hours. Logistic regression models were performed including baseline characteristics as exposures in the model and steroid response as the outcome. Main outcome measures were the proportion of eyes developing steroid response, risk factors for developing steroid response, and duration of steroid response.

Results

Of the 150 dropless and 218 conventional cases, 26 eyes developed steroid response (15 dropless and 11 conventional cases [10% vs 5%, P=0.096]). Risk factors for steroid response included dropless surgery (OR=2.43, 95% CI=1.03-6.02], P=0.046) and prior diagnosis of glaucoma (OR=7.18, 95% CI=2.66-19.22], P<0.001). Baseline IOP, age, sex, race, and axial length did not increase risk for steroid response. Of the eyes with steroid response, more dropless cases had an IOP elevation ≥30 days (9/15 eyes vs 1/11 eyes; P=0.008), including one patient with refractory IOP elevation in the dropless group who required urgent bilateral trabeculectomy for IOP control.

Conclusion

Dropless cataract surgery increases the risk of prolonged steroid response postoperatively. Patients with glaucoma have an increased risk of steroid response and may not be good candidates for dropless cataract surgery with subconjunctival triamcinolone.

Risk of Elevated Intraocular Pressure With Difluprednate in Patients With Non-Infectious Uveitis

PURPOSE

To evaluate the risk factors associated with clinically important intraocular pressure (IOP) elevation with topical difluprednate treatment in patients with non-infectious uveitis.

DESIGN

Retrospective cohort study.

METHODS

Fifty-four eyes of 54 patients with non-infectious uveitis treated with topical difluprednate at the current institution were included. Demographics and clinical characteristics of uveitis patients were collected. The main outcome measure was development of clinically important IOP elevation defined as IOP ≥21 mmHg and an increase of ≥10 mmHg from baseline.

RESULTS

A clinically important IOP elevation was observed in 17 patients (31.5%). The mean time to clinically important IOP elevation was 7.4±4.8 weeks (range 3-19). Statistically significant risk factors for incident clinically important IOP elevation were being a child (adjusted hazard ratio [aHR] 7.85 [95% CI 1.48-41.56], P = .02) and concurrent use of systemic steroids (aHR 5.31 [95% CI 1.18-24.00], P = .03). Patients with concurrent systemic corticosteroids developed clinically important IOP elevation earlier than those without systemic corticosteroid (mean 5.7±3.4 [range 3-14] vs 10.4±5.7 [range 4-19] weeks, P = .05). Incident IOP ≥30 mmHg occurred in 7 patients (13.0%). All patients responded well to the cessation of difluprednate and/or use of topical antiglaucomatous agents and no eyes required glaucoma surgery.

CONCLUSIONS

This study demonstrated that clinically important IOP elevation is common in uveitis patients with topical difluprednate treatment. Children and patients with concurrent systemic corticosteroids are at substantial risk of developing clinically important IOP elevation.

Surgical Outcomes of Ahmed Glaucoma Valve Implantation with Postoperative Use of Prednisolone Acetate Versus Difluprednate

PURPOSE

To evaluate the effect of postoperative topical prednisolone acetate and difluprednate on surgical outcomes of Ahmed Glaucoma Valve (AGV) implantation.

DESIGN

Retrospective comparative case series PARTICIPANTS: The study population consisted of 102 eyes of 90 patients, including 52 eyes that received prednisolone acetate 1% (PF group) and 50 eyes that received difluprednate 0.05% (DZ group).

METHODS

The medical records of consecutive patients who underwent AGV implantation at the University of California San Francisco were retrospectively reviewed. Patients in the PF group received prednisolone acetate 1% 6-8 times per day tapered over 5-6 months, and patients in the DZ group received difluprednate 0.05% 4 times daily tapered over 4 months postoperatively.

MAIN OUTCOME MEASURES

Intraocular pressure (IOP), number of glaucoma medications, visual acuity (VA), postoperative complications, and rate of treatment success.

RESULTS

At 1 year, IOP (mean ± standard deviation) was 12.4 ± 3.7 mmHg in the DZ group and 13.0 ± 4.0 mmHg in the PF group (P = 0.49). The number of glaucoma medications was 0.72 ± 0.71 in the DZ group and 1.09 ± 0.91 in the PF group (P = 0.04), with a reduction from baseline of 2.5 ± 1.0 glaucoma medications in the DZ group and 1.8 ± 1.6 medications in the PF group (P = 0.01). LogMAR VA (mean ± SD) was 0.55 ± 0.80 in the DZ group and 0.59 ± 0.65 in the DZ group after 1 year of follow-up (P = 0.81). The cumulative probability of success was 95.8% in the DZ group and 93.5% in the PF group at 1 year (P = 0.61). Postoperative complications occurred in 4 eyes (7.7%) in the DZ group and 6 eyes (12%) in the PF group (P = 0.52).

CONCLUSIONS

After 1 year, postoperative treatment with difluprednate 0.05% following AGV implantation resulted in similar IOP with use of fewer glaucoma medications compared with prednisolone acetate 1%. The rates of treatment success and surgical complications were comparable between the two groups during the first year of follow-up.

Difluprednate 0.05% twice a day vs Prednisolone acetate 1% four times a day for cataract postsurgical inflammation treatment: a non-inferiority trial

PURPOSE

To establish if Difluprednate 0.05% nanoemulsion (DIFL) twice a day (BID) is as effective as Prednisolone acetate 1% + Phenylephrine hydrochloride 0.12% suspension (PRED) four times a day (QID) on postsurgical inflammation treatment.

SETTING

4 private Argentine ophthalmological centers.

DESIGN

Non-inferiority, prospective, multicenter, double-blind, randomized, parallel-group, comparative trial.

METHODS

A total of 259 patients who underwent phacoemulsification randomly received DIFL or PRED starting the day before surgery and continuing for 28 days. The primary endpoint was central corneal thickness. Non-inferior anti-inflammatory efficacy was considered if the difference of corneal thickness between baseline and Day 4 did not differ beyond 17 µm between treatments. Secondary endpoints were cell & flare, corrected distance visual acuity (CDVA), endothelial cell count, OCT-central macular thickness, and intraocular pressure (IOP). All outcomes were evaluated at baseline, day 1, 4, and 28 after surgery.

RESULTS

225 patients finished the study. The difference in corneal thickness at baseline and Day 4 did not differ beyond 17 µm between treatments (IC95% -2.78µm - 14,84 µm), with no statistically significant difference between treatments (p = 0.523). There were not statistically significant differences between groups on total anterior chamber clearance at any study time (p > 0.05). No statistically significant differences were reported between treatments in CDVA (p = 0.455), endothelial cell count (p = 0.811), OCT-central macular thickness (p = 0.869), and in intraocular pressure outcome (p = 0.316).

CONCLUSIONS

Difluprednate administered BID is at least as effective as Prednisolone acetate administered QID on inflammatory treatment following cataract surgery.

Incidence and risk factors for postoperative intraocular pressure response to topical prednisolone eye drops in patients undergoing phacoemulsification

AIM/PURPOSE

To report the incidence, risk factors, and magnitude of steroid response in individuals receiving topical 1% prednisolone acetate eye drops following phacoemulsification surgery MATERIALS AND METHODS: Postoperative IOP of 1118 consecutive patients who had uneventful cataract surgery and used 1% topical prednisolone acetate were studied. Baseline ocular parameters like best-corrected visual acuity, IOP, and slit-lamp examination findings were noted preoperatively and at postoperative day 30. Incidence of postoperative intraocular pressure response to steroid was analyzed and graded as mild, moderate, or severe and risk factors studied.

RESULTS

The mean age of our study cohort was 59.49 ± 7.25 years. The overall incidence of steroid response was 3.2%, (2.8% being moderate responders, and 0.4% high responders). Mean preoperative IOP was 14.67 ± 2.2 mm Hg in the study cohort (n = 1118). Mean postoperative IOP was 21.33 ± 7.97 mm Hg in the steroid responder (SR) and 14.66 ± 2.8 mm Hg in the non-responder (NR), with a statistically significant difference from the baseline IOP in the SR group (p < 0.001) and no difference in the NR. Univariate analysis revealed younger age and high axial length as risk factors but on multiple regression analysis, only younger age < 50 years was found to be a significant risk factor for steroid response.

CONCLUSION

The overall steroid response in this population post-cataract surgery was low with most being moderate responders. Younger age and higher axial length were identified as risk factors for steroid response, and hence this warrants the judicious use of steroids in such individuals.

Topical Difluprednate for Early Corneal Graft Rejection After Penetrating Keratoplasty

Purpose

To evaluate the safety and efficacy of topical difluprednate ophthalmic emulsion use for prophylaxis of corneal graft rejection in patients undergoing penetrating keratoplasty.

Methods

This study reviewed the charts of patients undergoing penetrating keratoplasty who were treated with difluprednate (DP) ophthalmic emulsion postoperatively. At each follow-up visit, patients were followed for signs of graft rejection, cataract development, and intraocular pressure rise in addition to routine ocular examination.

Results

The charts of 36 patients (38 eyes) who underwent penetrating keratoplasty (PKP) (27 eyes) and PKP triple (11 eyes) were reviewed. All eyes were followed up for at least 8 months postoperatively. Five grafts developed rejection and three grafts subsequently failed. Six eyes had an increase of IOP that required use of antiglaucoma drops. Three eyes were switched from difluprednate to prednisolone acetate (PA) after persistent rise of IOP failed to respond to antiglaucoma drops. None of these cases needed glaucoma surgery. Two patients developed cataract during the follow-up period (out of 12 phakic eyes).

Conclusion

Topical difluprednate is potentially effective and safe in preventing graft rejection after penetrating keratoplasty. Larger prospective clinical trials are warranted.

Corticosteroids in ophthalmology: drug delivery innovations, pharmacology, clinical applications, and future perspectives

Corticosteroids remain the mainstay of the treatment for various ocular conditions affecting the ocular surface, anterior and posterior segments of the eye due to their anti-inflammatory, anti-oedematous, and anti-neovascularization properties. Prednisolone, prednisolone acetate, dexamethasone, triamcinolone acetonide, fluocinolone acetonide, and loteprednol etabonate are amongst the most widely used ophthalmic corticosteroids. Corticosteroids differ in their activity and potency in the eye due to their inherent pharmacological and pharmaceutical differences. Different routes and regimens are available for ocular administration of corticosteroids. Conventional topical application to the eye is the route of choice when targeting diseases affecting the ocular surface and anterior segment, while periocular, intravitreal, and suprachoroidal injections can be potentially effective for posterior segment diseases. Corticosteroid-induced intraocular pressure elevation and cataract formation remain the most significant local risks following topical as well as systemic corticosteroid administration. Invasive drug administration via intracameral, subconjunctival, and intravitreal injection can enhance ocular bioavailability and minimize dose and dosing frequency of administration, yet may exacerbate ocular side effects of corticosteroids. This review provides a critical appraisal of the ophthalmic uses of corticosteroid, routes of administration, drug delivery fundamentals and novel ocular implantable steroid delivery systems, factors influencing side effects, and future perspectives for ocular corticosteroid therapy.

Comparison of topically administered 0.05% difluprednate and 1% prednisolone acetate for inhibition of aqueocentesis-induced breakdown of the blood-aqueous barrier in healthy dogs

OBJECTIVE

To compare the efficacy of 0.05% difluprednate ophthalmic emulsion and 1% prednisolone acetate ophthalmic suspension for controlling aqueocentesis-induced breakdown of the blood-aqueous barrier in healthy dogs.

ANIMALS

34 healthy dogs.

PROCEDURES

Dogs were allocated to 5 groups (6 to 8 dogs/group) to receive 0.05% difluprednate, 1% prednisolone acetate, or saline (0.9% NaCl) solution (control treatment) in both eyes 2 or 4 times daily. Eye drops were administered topically for 5 consecutive days. Anterior chamber paracentesis (aqueocentesis) was performed in 1 eye on the third day. Automated fluorophotometry was performed immediately before and 20 minutes and 24 and 48 hours after aqueocentesis. Relative fluorescence (RF), defined as fluorescence of the eye that had undergone aqueocentesis divided by fluorescence of the contralateral eye, was calculated to help control for variation among dogs.

RESULTS

Mean RF was significantly lower at 24 hours after aqueocentesis in dogs treated twice daily with 0.05% difluprednate or 4 times daily with 1% prednisolone acetate than in dogs receiving the control treatment. At 48 hours after aqueocentesis, mean RF was significantly lower in dogs treated 4 times daily with 1% prednisolone acetate than in control dogs. Mean RF differed over time in dogs treated 4 times daily with 0.05% difluprednate but did not differ over time for any of the other treatments.

CONCLUSIONS AND CLINICAL RELEVANCE

All 4 treatments were effective for reducing aqueocentesis-induced anterior uveitis in healthy dogs regardless of the drug or frequency of administration. Topical ophthalmic administration of 0.05% difluprednate may be a viable treatment option for dogs with anterior uveitis and warrants further study.

Difluprednate 0.05% versus Prednisolone Acetate Post-Phacoemulsification for Inflammation and Pain: An Efficacy and Safety Clinical Trial

Background

The purpose of this study was to compare the efficacy and safety of difluprednate 0.05% (PRO-145) versus prednisolone acetate 1% (Prednefrin^® SF), for management of postoperative inflammation and pain, after cataract surgery.

Methods

This was a Phase III, multicenter, prospective, double-blind, clinical trial. Intent-to-treat population included 178 post-phacoemulsification patients that were assigned to receive either PRO-145, or prednisolone. One day after unilateral eye surgery, patients instilled a drop 4 times a day for 14 days (then tapering the dose downward for 14 days). The primary efficacy endpoints were anterior chamber (AC) cell grade and flare. Other parameters measured included: retinal central thickness (measured via OCT), conjunctival hyperemia, edema, pain and photophobia. Tolerability and safety were assessed through burning, itching, foreign body sensation, visual acuity (VA), intraocular pressure (IOP) and incidence of adverse events (AE).

Results

A total of 171 subjects were randomized (1:1) and completed the study. Compared to day 1, there was a significant improvement in the AC cell count and flare in both groups by the final visit (80.2% vs 88.4%, p=1.000). Conjunctival hyperemia improved in a similar fashion (81.2% vs 79%, p=0.234) in both PRO-145 and prednisolone groups, without differences between them. This was also observed for edema (82.4% vs 82.5%, p=0.246), pain (15.3% vs 7%, p=0.497) and photophobia (16.4% vs 15.1%, p=0.246), respectively. There was no significant difference between treatments for any tolerability parameter studied. Finally, at the 4-week postoperative visit, there were no significant differences between treatments for VA, IOP and AE results (p-values; 0.095, 0.053 and 0.099, respectively).

Conclusion

The results of this study suggest that PRO-145 is as effective and safe as prednisolone acetate in treating postoperative inflammation and pain in patients undergoing phacoemulsification. The study was registered at ClinicalTrials.gov as NCT03693989.

Comparison of prednisolone acetate 1.0% and difluprednate ophthalmic emulsion 0.05% after cataract surgery: Incidence of postoperative steroid-induced ocular hypertension

PURPOSE

To compare intraocular pressure (IOP) outcomes between 2 common, commercially available corticosteroid drops: difluprednate ophthalmic emulsion 0.05% and prednisolone acetate 1.0%.

SETTING

TLC Eyecare and Laser Centers, Jackson, Michigan, USA.

DESIGN

Retrospective chart review.

METHODS

The outcomes of consecutive patients who had uneventful cataract surgery from April 2013 to September 2013 and used prednisolone acetate postoperatively were compared with the outcomes of consecutive patients who had uneventful cataract surgery from June 2014 to October 2014 and used difluprednate postoperatively.

RESULTS

The study included 224 eyes treated with prednisolone acetate 4 times daily for 30 days and 225 eyes treated with difluprednate 2 times daily for 30 days. There was no significant difference between the 2 groups in age, sex, or race. In addition, the mean IOP did not differ significantly between the prednisolone acetate group and the difluprednate group at the preoperative measurement or 1 month after surgery, nor was there a difference in the 1-month change in IOP between groups. No association was found between the incidence of a 6 mm Hg or higher increase in IOP 1 month after surgery and steroid treatment. One month postoperatively, 4 eyes in the prednisolone acetate group and 5 eyes in the difluprednate group had an IOP higher than 21 mm Hg.

CONCLUSIONS

There was no significant difference in the mean IOP or percentages showing IOP elevation between eyes treated with difluprednate and eyes treated with prednisolone acetate after cataract surgery. This was likely the result of low-frequency dosing and short duration of steroid use.

Difluprednate versus Prednisolone Acetate after Cataract Surgery: a Systematic Review and Meta-Analysis

OBJECTIVE

Topical steroids are the cornerstone in controlling the inflammation after cataract surgery. Prednisolone acetate and difluprednate are the two main products for this purpose. However, it is unclear which one should be used in terms of effectiveness and safety.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Medline via PubMed, Cochrane Central Register of Controlled Trials, Web of science and clinicaltrials.gov were searched through 10 January 2018, and updated on 20 July 2019, in addition to researching the references' lists of the relevant articles.

ELIGIBILITY CRITERIA

Randomised-controlled trials (RCTs) comparing difluprednate and prednisolone acetate regardless of the dosing regimen used.

DATA EXTRACTION AND SYNTHESIS

Two independent authors assessed the included RCTs regarding the risk of bias using the Cochrane tool. Relevant data were extracted, and meta-analysis was conducted using a random-effects model. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to appraise the evidence quality.

RESULTS

We included six RCTs with 883 patients: 441 received difluprednate and 442 received prednisolone acetate. The evidence quality was graded as moderate for corneal oedema and intraocular pressure and low for anterior chamber (AC) clearance. After small incision cataract surgery, difluprednate was superior in clearing AC cells at 1 week (OR=2.5, p>0.00001) and at 2 weeks (OR=2.5, p=0.04), as well as clearing the AC flare at 2 weeks (OR=6.7, p=0.04). After phacoemulsification, difluprednate was superior in terms of corneal clarity at 1 day (OR=2.6, p=0.02) and 1 week after surgery (OR=1.96, p=0.0007). No statistically significant difference was detected between both agents at 1 month in effectiveness. Also, both agents were safe, evaluated by the ocular hypertension (OR=1.23, p=0.8).

CONCLUSION

With low-to-moderate certainty, difluprednate and prednisolone acetate are safe agents for controlling the inflammation after cataract surgery. Difluprednate showed significant superiority in terms of AC cells and AC flare at 2 weeks postoperatively.

Risk of intraocular pressure elevation after topical steroids in children and adults: A systematic review

Topical steroids may induce a rise in intraocular pressure. The risk may increase with prolonged use, high frequency of administration, young age, higher ocular penetrance and higher anti-inflammatory potency. We aimed to study this relationship by comparing published rates of intraocular pressure elevation following administration of topical steroids and compared the risk of higher versus lower dosage regimes, high- versus low-potency/penetration steroids and adults versus children. Data sources used were Ovid Embase, Ovid Medline, the Cochrane Central Register of Controlled Trials, Web of Science, Scopus, CINHAL Plus and LILACS. Eligible studies were randomised controlled trials of topical steroids versus any other topical steroid, nonsteroidal anti-inflammatory drugs, placebo or vehicle, or a different mode of administration administered for 7 days or longer that reported intraocular pressure elevation from baseline as >10, 6-15 or >15 mm Hg in adults or children. Risks of bias were reviewed using the GRADE quality approach. Data were extracted into the software package, RevMan, Version 5 (Cochrane Collaboration). In total, 43 studies were included. Meta-analysis was not possible. Topical steroids of lower anti-inflammatory potency, and with reduced intraocular penetration, are associated with reduced incidence of intraocular pressure elevation. A comparison of data in children and adults is limited by the use of different reporting systems. The principal obstacle to meta-analysis is the different reporting systems used to categorise intraocular pressure elevation. We recommend future studies should report intraocular pressure elevation >10 mm Hg from baseline to allow meta-analysis of data.

Comparison of Efficacy of Difluprednate 0.05% and Loteprednol Gel 0.5% After Cataract Surgery

PURPOSE

To compare the outcomes and complications of topical difluprednate 0.05% and loteprednol gel 0.5% after routine cataract surgery.

METHODS

Subjects received either difluprednate emulsion 0.05% (n=30 eyes) or loteprednol gel 0.5% (n=30 eyes) after routine cataract surgery. Topical steroid drops were initiated 3 days before cataract surgery and continued for 2 weeks postoperatively. Anterior chamber (AC) cell grade, corneal edema, corneal pachymetry, visual acuity, ocular surface quality (Oxford scale), and intraocular pressure (IOP) were evaluated at 1 day, 1 week, and 1 month postoperatively.

RESULTS

Patients treated with difluprednate or loteprednol had statistically similar resolution of their AC cell grade and corneal edema at 1 day, 1 week, and 1 month postoperatively (P>0.05 at each study visit). Difluprednate-treated and loteprednol-treated eyes achieved a mean best-corrected visual acuity of at least 20/25 by 1 week postoperatively (0.055 and 0.061 logarithm of the minimum angle of resolution, respectively; P=0.82). The nasal ocular surface quality at 1 week had improved in loteprednol-treated eyes compared with difluprednate-treated eyes (1.0 vs. 1.9 Oxford score, respectively; P<0.001), but similar at all other visits. There was no statistical difference between IOP levels between both treatment groups (P>0.05). In the difluprednate-treated group, one patient developed rebound inflammation and two patients developed cystoid macular edema at their 1-month postoperative visit.

CONCLUSIONS

The anti-inflammatory effect, visual recovery, and IOP of patients using topical difluprednate or loteprednol gel after cataract surgery are equivalent. There may be an additional short-term benefit of loteprednol gel in protecting the ocular surface after cataract surgery.

Effect of 0.05% Difluprednate Ophthalmic Emulsion on Proinflammatory Cytokine Levels After Retinal Laser Photocoagulation in Rabbits

PURPOSE

We aimed to evaluate the effect of the topical application of a strong corticosteroid, difluprednate, on the levels of inflammatory and angiogenic cytokine in the vitreous and aqueous humor after laser photocoagulation.

METHODS

Pigmented rabbits were treated with retinal laser photocoagulation and divided into 4 groups, namely control (no additional treatment), topical application of difluprednate 0.05%, betamethasone sodium phosphate 0.1%, and sub-Tenon injection of triamcinolone acetonide (STTA). Samples of vitreous and aqueous humor were collected on posttreatment days 0, 1, 7, and 14. The levels of intraocular vascular endothelial growth factor (VEGF), interleukin-6 (IL-6), intercellular adhesion molecule-1 (ICAM-1), and monocyte chemotactic protein-1 (MCP-1) were measured using an immunoassay. Intraocular pressure (IOP) was monitored in each group.

RESULTS

VEGF, IL-6, ICAM-1, and MCP-1 were significantly elevated on day 1 and were reduced in both the vitreous and aqueous humor following topical application of difluprednate and STTA. Topical betamethasone reduced their levels in the aqueous humor but not in the vitreous. A significant increase of IOP induced by difluprednate returned to control levels after withdrawal of administration.

CONCLUSION

Although the elevation of IOP was an expected, manageable side effect, topical application of difluprednate was more effective than STTA and betamethasone for reducing inflammatory cytokine levels after laser treatment.

RESOLUTION OF NONINFECTIOUS UVEITIC CYSTOID MACULAR EDEMA WITH TOPICAL DIFLUPREDNATE

PURPOSE

To evaluate the short-term safety and efficacy of topical difluprednate (0.05%) for the treatment of noninfectious uveitic cystoid macular edema.

METHODS

Twenty-seven patients (35 eyes) undergoing treatment with difluprednate 4 times daily for 3 weeks for noninfectious uveitic cystoid macular edema were reviewed for visual acuity, intraocular pressure, optical coherence tomography, and fluorescein angiography results. A mixed model analysis was fit with each measure as the outcome, visit as the primary predictor, and patient and eye as random effects.

RESULTS

Mean central foveal thickness decreased by 117 μm (P < 0.001) at 30 ± 15 days, 124 μm (P < 0.001) at 60 ± 15 days, and 152 μm (P < 0.001) at 180 ± 30 days. Complete resolution of intraretinal fluid was observed in 15 of 34 (44%) eyes at 30 ± 15 days, 11 of 21 (52%) eyes at 60 ± 15 days, and 9 of 12 (75%) eyes at 180 ± 30 days. Improvement in fluorescein leakage was noted in 7 of 8 eyes (88%). Visual acuity improved by a mean of 5 letters (P = 0.001) at 30 ± 15 days, 5.5 letters (P = 0.007) at 60 ± 15 days, and 7 letters (P = 0.032) at 180 ± 30 days. Mean increase in intraocular pressure was 1.48 mmHg at 30 ± 15 days (P = 0.080), 1.92 mmHg at 60 ± 15 days (P = 0.110), and 6.18 mmHg (P = 0.001) at 180 ± 30 days.

CONCLUSION

Topical difluprednate is a well-tolerated and effective treatment for noninfectious uveitic cystoid macular edema with decreased central foveal thickness, mild improvement in visual acuity, and elevation of intraocular pressure observed in a few patients.

Efficacy of nepafenac ophthalmic suspension 0.1% in improving clinical outcomes following cataract surgery in patients with diabetes: an analysis of two randomized studies

OBJECTIVE

To assess the efficacy of nepafenac 0.1% ophthalmic suspension in improving the clinical outcomes following cataract surgery (CS) in patients with nonproliferative diabetic retinopathy.

METHODS

In two similar multicenter, randomized studies, patients received either nepafenac 0.1% or vehicle, instilled three times daily starting a day prior to surgery and continuing for 90 days postoperatively. A post hoc analysis of these two studies was conducted to assess 1) the likelihood for development of postoperative macular edema (ME), based on the percentage of patients who developed ME (≥30% increase from preoperative baseline in central subfield macular thickness) within 90 days following CS and 2) best-corrected visual acuity (BCVA) endpoints, including the percentage of patients with a BCVA improvement of ≥15 letters from preoperative baseline to Day 14 and maintained through Day 90. Results for individual studies and their pooled estimates (only visual acuity endpoints) are reported. Primary inference was based on odds ratio (OR).

RESULTS

This post hoc analysis included 411 patients (nepafenac 0.1%: 205; vehicle: 206). The incidence of postoperative ME within 90 days of CS was notably lower in the nepafenac-treated patients than in vehicle-treated patients (study 1: 3.2% vs 16.7%; OR =0.2, 95% confidence interval [CI] =0.1, 0.5, P=0.001; study 2: 5.0% vs 17.5%; OR =0.2, 95% CI =0.1, 0.8, P=0.018). A higher percentage of nepafenac-treated patients than vehicle-treated patients gained ≥15 letters from preoperative baseline to Day 14, which was maintained through Day 90 (study 1: 38.4% vs 21.4%; OR =2.4, 95% CI =1.4, 4.2, P=0.003; study 2: 35.0% vs 25.0%; OR =1.6, 95% CI =0.8, 3.2, P=0.172; pooled: 37.1% vs 22.8%; OR =2.0, 95% CI =1.3, 3.1, P=0.001). The odds of >5-letter and >10-letter loss in BCVA from postoperative Day 7 were higher in vehicle-treated than in nepafenac-treated patients.

CONCLUSION

These results support the clinical benefit of prophylactic use of nepafenac 0.1% for reducing the risk of postoperative ME and for improvement in BCVA outcomes following CS in patients with nonproliferative diabetic retinopathy.

A retrospective analysis of intraocular pressure changes after cataract surgery with the use of prednisolone acetate 1% versus difluprednate 0.05%

Purpose

To compare the effect of topical prednisolone acetate 1% (PA) used after routine cataract surgery to the effect of difluprednate 0.05% (DFBA) used for the same indication on intraocular pressure (IOP).

Methods

An electronic query was created to gather information from all cataract surgeries between January 2010 and January 2015 within the electronic health record database at Barnet Dulaney Perkins, a multicenter, multiphysician private practice in Phoenix, Arizona. Information collected included age, sex, diabetes status, glaucoma history, medication regimen (use of PA or DFBA), and IOP before surgery, 5–10 days postoperatively (TP1) and 3–6 weeks postoperatively (TP2). Postoperative IOP measurements were compared to baseline IOP measurement in each patient.

Results

Regardless of steroid used, all patients in this study experienced an increase in IOP within TP1 and returned to baseline IOP (±2.0 mmHg) by TP2. Patients who received DFBA showed a statistically significant increase in IOP at TP1 compared to those on PA (P<0.001) with the mean IOP an average 0.60 mmHg higher (95% CI =0.3, 0.9). The odds ratio of a clinically significantly increased IOP at TP1 (defined as overall IOP ≥21 mmHg and an increase of ≥10 mmHg) in DFBA-treated patients was 1.84 (95% CI =1.4, 2.6). In patients treated with PA, 3% reached a significantly increased IOP, compared to 4.4% of patients in the DFBA group (P<0.05). Risk factors for increased IOP were identified, and include advanced age (>75) (P<0.005) and a history of glaucoma (P<0.001).

Conclusion

In postoperative cataract patients, use of DFBA increased the risk of a clinically significant IOP increase.

Central corneal thickness changes in bevel-up versus bevel-down phacoemulsification cataract surgery: study protocol for a randomised, triple-blind, parallel group trial

INTRODUCTION

Corneal endothelial damage following phacoemulsification is still one of the major concerns of modern day cataract surgery. Although many techniques have been proposed, the risks of posterior capsular rupture and corneal endothelium damage persist. In theory, damage to the corneal endothelium is minimised by delivering the lowest phaco energy only in the direction necessary to emulsify the lens nucleus. Hence, it is believed that the bevel of the needle should be turned towards the nucleus or the nuclear fragment (ie, bevel-down. However, there is a difference of opinion among ophthalmologists with reference to the phaco tip's position (bevel-up vs bevel-down) during phacoemulsification. This subject has not been extensively studied earlier.

METHODS AND ANALYSIS

This is a prospective, triple-blinded (trial participant, outcome assessor and the data analyst), randomised controlled trial with 2 parallel groups and with an allocation ratio of 1:1. It will be conducted in a tertiary care hospital, Mangaluru, India. The objective is to compare the postoperative central corneal thickness changes between the bevel-up and bevel-down techniques of phacoemulsification. Patients aged >18 years with immature cataract undergoing phacoemulsification will be selected for the study. The important exclusion criteria are the history of previous significant ocular trauma or intraocular surgery, corneal pathology, pseudoexfoliation syndrome, intraocular inflammation, a preoperative fully dilated pupil <6 mm, anterior chamber depth <2.5 mm and nuclear sclerosis grade >4. After randomisation, patients will undergo phacoemulsification surgery either by a bevel-up or bevel-down procedure. With an estimated power of 80%, the calculated sample size is 55 patients in each group. The recruitment will start from April 2016.

ETHICS AND DISSEMINATION

Yenepoya University Ethics Committee, India has approved the study protocol (YUEC/148/2016 on 18 February 2016). It complies with the Declaration of Helsinki, local laws and the International Council for Harmonization-good clinical practices.

TRIAL REGISTRATION NUMBER

CTRI/2016/02/006691; Pre-results.

Initial Clinical Experience With the CyPass Micro-Stent: Safety and Surgical Outcomes of a Novel Supraciliary Microstent

PURPOSE

To evaluate safety and clinical outcomes of a novel supraciliary device, the CyPass Micro-Stent, for surgical treatment of open-angle glaucoma when implanted in conjunction with cataract surgery.

PATIENTS AND METHODS

Subjects (n=142) with open-angle glaucoma and cataract underwent combined phacoemulsification, with intraocular lens insertion, and microstent implantation into the supraciliary space of study eyes (n=167). Two analysis cohorts were prespecified based upon medicated baseline intraocular pressure (IOP): ≥21 mm Hg (cohort 1, n=65) or <21 mm Hg (cohort 2, n=102). Glaucoma medications were discontinued or tapered at surgery, and restarted at investigator discretion. The main postoperative outcome measures were adverse events, IOP changes, and number of IOP-lowering medications.

RESULTS

Mean±SD follow-up was 294±121 days. No major intraoperative or postoperative complications occurred. Preoperative baseline mean IOP was 20.2±6.0 mm Hg and mean number of IOP-lowering medications was 2.0±1.1. Cohort 1 showed a 35% decrease in mean IOP and a 49% reduction in mean glaucoma medication usage; cohort 2 demonstrated a 75% reduction in mean medication usage while maintaining mean IOP<21 mm Hg. For all eyes, mean IOP at 12 months was 15.9±3.1 mm Hg (14% reduction from baseline). Early and late postoperative IOP elevation occurred in 1.2% and 1.8% of eyes, respectively. Two subjects developed mild transient hyphema, and none exhibited prolonged inflammation, persistent hypotony, or hypotony maculopathy.

CONCLUSIONS

CyPass Micro-Stent implantation, combined with cataract surgery, resulted in minimal complications and reduced IOP and IOP-lowering medication use at 12 months postoperatively.

Prevention of Cystoid Macular Edema After Cataract Surgery in Nondiabetic and Diabetic Patients: A Systematic Review and Meta-Analysis

PURPOSE

To evaluate the optimum medical strategy to prevent cystoid macular edema (CME) after cataract surgery.

DESIGN

Systematic review and meta-analysis.

METHODS

setting: Cochrane, MEDLINE, and EMBASE databases were searched to identify eligible randomized controlled trials (RCTs).

STUDY POPULATION

RCTs comparing medical strategies to prevent CME after uncomplicated cataract surgery in nondiabetic and diabetic patients.

OBSERVATION PROCEDURES

Data were extracted by 2 authors independently. Quality of individual RCTs was assessed using the Cochrane Collaboration's tool for assessing risk of bias and Delphi criteria.

MAIN OUTCOME MEASURES

Odds of developing CME within 3 months postoperatively and foveal thickness, macular volume and corrected distance visual acuity change within 3 months postoperatively, as compared to baseline.

RESULTS

Seventeen trials reported incidence rates. Topical nonsteroidal anti-inflammatory drugs (NSAIDs) significantly reduced the odds of developing CME as compared to topical corticosteroids in nondiabetic (odds ratio [OR] 0.11; 95% confidence interval [95% CI] 0.03-0.37) and mixed populations (OR 0.05; 95% CI 0.02-0.11). A combination of topical corticosteroids and NSAIDs significantly reduced the odds of developing CME as compared to topical corticosteroids in nondiabetic (OR 0.21; 95% CI 0.10-0.44) and diabetic patients (OR 0.17; 95% CI 0.05-0.50). Intravitreal corticosteroid or anti-vascular endothelial growth factor injections did not show any additional benefit in diabetic subjects.

CONCLUSIONS

Topical NSAIDs significantly reduced the odds of developing CME, as compared to topical corticosteroids, in nondiabetic and mixed populations. A combination of topical NSAIDs and corticosteroids reduced the odds of developing CME in nondiabetic and diabetic patients, as compared to topical corticosteroids.

Difluprednate 0.05% versus prednisolone acetate 1% for endogenous anterior uveitis: a phase III, multicenter, randomized study

PURPOSE

Endogenous anterior uveitis (AU), when untreated, may lead to vision loss. This study compared the safety and efficacy of difluprednate versus prednisolone acetate for the treatment of this condition.

METHODS

This phase III, double-masked, noninferiority study randomized patients with mild to moderate endogenous AU to receive difluprednate 0.05% (n = 56) four times daily, alternating with vehicle four times daily, or prednisolone acetate 1% (n = 54) eight times daily. The 14-day treatment period was followed by a 14-day dose-tapering period and a 14-day observation period. The primary efficacy end point was change in anterior chamber cell grade (range, 0 for ≤1 cell to 4 for >50 cells) from baseline to day 14.

RESULTS

At day 14, the mean change in anterior chamber cell grade with difluprednate was noninferior to that with prednisolone acetate (-2.2 vs. -2.0, P = 0.16). The proportions of difluprednate-treated patients versus prednisolone acetate-treated patients demonstrating complete clearing of anterior chamber cells at day 3 were 13.0% vs. 2.1% (P = 0.046) and at day 21 were 73.9% vs. 63.8% (P = 0.013). A significant between-group difference in the mean IOP increase was seen at day 3 (2.5 mm Hg for difluprednate-treated patients and 0.1 mm Hg for prednisolone acetate-treated patients, P = 0.0013) but not at other time points. The mean IOP values in both groups remained less than 21 mm Hg throughout the study.

CONCLUSIONS

Difluprednate 0.05% four times daily is well tolerated and is noninferior to prednisolone acetate 1% eight times daily for the treatment of endogenous AU. (ClinicalTrials.gov number, NCT01201798.).

Loteprednol etabonate ophthalmic suspension 0.5 %: efficacy and safety for postoperative anti-inflammatory use

Topical corticosteroids are routinely used as postoperative ocular anti-inflammatory drugs; however, adverse effects such as increased intraocular pressure (IOP) are observed with their use. While older corticosteroids such as dexamethasone and prednisolone acetate offer good anti-inflammatory efficacy, clinically significant increases in IOP (≥10 mmHg) are often associated with their use. Loteprednol etabonate, a novel C-20 ester-based corticosteroid, was retrometabolically designed to offer potent anti-inflammatory efficacy but with decreased impact on IOP. After exerting its therapeutic effects on the site of action, loteprednol etabonate is rapidly converted to inactive metabolites, resulting in fewer adverse effects. Randomized controlled studies have demonstrated the clinical efficacy and safety of loteprednol etabonate ophthalmic suspension 0.5 % for the treatment of postoperative inflammation in post-cataract patients with few patients, if any, exhibiting clinically significant increases (≥10 mmHg) in IOP. Furthermore, safety studies demonstrated a minimal effect of loteprednol etabonate on IOP with long-term use or in steroid responders with a much lower propensity to increase IOP relative to prednisolone acetate or dexamethasone. The anti-inflammatory treatment effect of loteprednol etabonate appears to be similar to that of rimexolone and difluprednate with less impact on IOP compared to difluprednate, although confirmatory comparative studies are needed. The available clinical data suggest that loteprednol etabonate is an efficacious and safe corticosteroid for the treatment of postoperative inflammation.

Difluprednate for the prevention of ocular inflammation postsurgery: an update

Purpose:

To review the most recent published data regarding the novel potent steroid, difluprednate ophthalmic emulsion, 0.05%.

Methods:

A comprehensive search of recent published literature including difluprednate was performed. Clinical studies relevant to the characteristics and clinical efficacy of difluprednate in controlling postoperative inflammation were included, and a synopsis of each study was developed.

Results:

Several recent publications were identified in which difluprednate was shown to be efficacious in the treatment of postoperative inflammation in different clinical settings, including a novel perioperative regimen. Additional literature retrieved from this search included data on the relative potency of difluprednate, potential utility in the posterior segment, as well as the advantages of the emulsion formulation.

Conclusion:

Difluprednate has been studied extensively and shown in recent literature to be a safe and effective topical anti-inflammatory drug. The proven strength and unique formulation of difluprednate, along with its potent efficacy in treating and preventing inflammation, provides clinicians with a beneficial treatment option.