Nepafenac-associated corneal melt

Corneal Melt and Perforation Associated With Prolonged Oral Non-Steroidal Anti-Inflammatory Drug (NSAID) Use: A Case Report

Corneal melt and perforation can arise from various etiologies, including the use of toxic topical drops, particularly topical non-steroidal anti-inflammatory drugs (NSAIDs). The literature has frequently documented the association between the use of topical NSAIDs and the subsequent development of corneal ulcers. More recently, reports have emerged linking the use of oral NSAIDs and colchicine to impaired corneal wound healing and corneal perforation. This case report presents an instance of corneal melting and subsequent perforation in a medically unburdened patient who had been self-administering oral NSAIDs for one year. The evidence presented in this report suggests a plausible association between the prolonged administration of oral NSAIDs and corneal melt. Consequently, healthcare practitioners should be mindful of this potential risk when considering the prolonged use of oral NSAIDs.

The use of topical nalbuphine in different concentrations to control pain after photorefractive keratectomy

PURPOSE

This is a randomized controlled study aiming to evaluate the safety and efficacy of two different concentrations of topical nalbuphine hydrochloride, when used to relieve pain in the first days following photorefractive keratectomy (PRK).

METHODS

This is a prospective double blinded randomized clinical trial that included 189 patients who had PRK for correction of low and moderate refractive errors. Patients were randomly assigned to three groups according to the eye drops given to relieve pain in the first three postoperative days; the first group received topical nalbuphine with a concentration of 2 mg/ml (Group A = 64 patients), the second group received topical nalbuphine in a concentration of 1 mg/ml (Group B = 69 patients) and the third group received topical artificial tears only (Group C = 56 patients).The patients were asked to rate their pain daily using a numeric rating scale and to record the number of drops instillation times/day. The time needed for complete epithelial healing, best-corrected visual acuity (BCVA) and spherical equivalent after three months were recorded in each group.

RESULTS

In the first three days, there was a statistically significant difference in pain score among the three groups with lower values in the two topical nalbuphine groups when compared with the control group receiving artificial tears. Moreover, the higher concentration group showed significantly lower pain score and less number of drops used /day in comparison with the lower concentration group.There were no statistically significant differences in epithelial healing time, BCVA and spherical equivalent after three months among the three groups.

CONCLUSION

The use of topical nalbuphine is effective in relieving pain in the first few days following PRK and this pain relief is not associated with any compromise regarding epithelial healing nor refractive outcome. The pain control with 2 mg/ml concentration is significantly higher than that with 1 mg/ml concentration of nalbuphine. Trial registration numberISRCTN21394752 https://doi.org/10.1186/ISRCTN21394752 The trial is retrospectively registered in ISRCTN registry at March 08, 2021.

Crosslinking und Keratokonus

Ein Keratokonus führt zu einer progressiven Vorwölbung und Verdünnung der Hornhaut. Um dies aufzuhalten, kann ein Crosslinking durchgeführt werden. Dabei ist eine Behandlung nach dem „Dresdener Protokoll“ eine effektive und sichere Behandlungsmöglichkeit, aber auch zahlreiche neue Anwendungsprotokolle (akzeleriertes Crosslinking, transepitheliales Crosslinking) und sogar weitere Indikationen (refraktive Eingriffe, infektiöse Keratitis) wurden in den letzten Jahren veröffentlicht.

[Crosslinking and Keratoconus]

Keratoconus leads to a progressive protrusion and thinning of the cornea. In order to stop this, corneal crosslinking can be performed if the progression of the disease is proven. Crosslinking according to the "Dresden protocol" includes abrasion of the corneal epithelium, application of riboflavin eye drops and irradiation with UV-A light of an intensity of 3 mW/cm² for 30 minutes. The efficacy has been shown in several prospective randomized studies. One of the more recent developments is accelerated crosslinking, which allows a shorter irradiation time. On the other hand, the possibility of transepithelial crosslinking was presented, which does not require an abrasion of the cornea. This should reduce the occurrence of postoperative pain. The range of indications has also been expanded. Corneal crosslinking is used for post-LASIK keratectasia as well. It is also being considered for use in infectious keratitis. Topographically controlled crosslinking can likewise be used to try to positively influence the refractive power of the cornea. The risks of crosslinking include the occurrence of pain, haze or scarring, endothelial cell damage and, rarely, the occurrence of keratitis.

Prophylactic use of nonsteroidal anti-inflammatory drugs after cataract surgery and corneal melt

Purpose:

To describe a case where prophylactic use of nonsteroidal anti-inflammatory drugs (NSAID) eye drops lead to recurrent corneal melt with loss of vision and a brief literature review.

Methods:

This is a case report of an 84-year-old diabetic female with chronic dry eye, operated by two different surgeons on each eye at different time intervals. She received topical NSAID prophylaxis after the second surgery only, which led to blindness due to recurrent corneal melt and chronic choroidal effusions. We also present a brief literature review.

Results:

This lady presented with corneal melt and perforation 5 days following the use of topical NSAIDs prophylaxis after a routine cataract surgery in the second eye. Unfortunately, all efforts to save her vision and eye were unsuccessful as she developed repeated complications in spite of corneal gluing, amniotic membrane, penetrating keratoplasty, and tarsorrhaphy. She also had chronic choroidal effusions. She ended up with an opaque cornea and a subtotal tarsorrhaphy, with no other option to improve her vision as she did not qualify for sedation or general anesthesia due to her poor systemic health.

Conclusion:

Although it is a common practice for diabetic patients to have topical NSAIDs prophylaxis in combination with steroid eye drops to reduce the risk of cystoid macular edema after cataract surgery, the elderly diabetic patients with concomitant dry eyes should be considered high risk for corneal melt and should be closely monitored. This case highlights the rare but serious complication of topical NSAIDs prophylaxis in the vulnerable cornea, which warrants careful consideration.

Cataract Surgery in Dry Eye Disease: Visual Outcomes and Complications

Purpose: To describe the visual outcomes and complications following cataract surgery in dry eye disease (DED). Methods: This retrospective study included 668 eyes of 399 patients with DED, who underwent cataract surgery between 2011 and 2019 at our multi-tier ophthalmology hospital network. Based on etiology, they were divided into three groups: cicatrizing conjunctivitis (CC), meibomian gland dysfunction (MGD), and Sjogren's syndrome (SS). The data on demographics, visual impairment, surgical technique, visual outcomes, and complications were collected using an electronic medical record system. Median LogMAR best corrected visual acuity (BCVA) with interquartile range (IQR) was compared using Wilcoxon's rank sum test. Results: The median age at which cataract surgery was performed was 58 (IQR: 47-65) years. Etiology of DED was CC in 279, MGD in 255, and SS in 134 eyes. Most (471) eyes underwent phacoemulsification, under peribulbar anesthesia (548) through a temporal clear corneal incision (209) with foldable intraocular lens implantation (417). The overall median LogMAR BCVA improved from 1.1 (IQR: 0.6-2.1) at baseline to 0.3 (IQR: 0.1-0.7) and 0.1 (IQR: 0-0.65) at 1 and 6 weeks (p < 0.0001) post-operatively. The median 6 weeks post-operative BCVA was 0.3, 0.1, and 0.1 in CC, MGD, and SS, respectively, and significantly better than at baseline (p < 0.0001). The leading cause of sub-optimal vision was corneal scarring (44; 9%), and the most common complication was posterior capsular rupture with vitreous loss (23; 3%). Conclusion: Cataract surgery has good visual outcomes in patients with DED, without any disconcerting rate of complications. Pre-existing keratopathy is the main determinant of the extent of post-operative visual recovery.

Acute corneal perforation 1 week following uncomplicated cataract surgery: the implication of undiagnosed dry eye disease and topical NSAIDs

Dry eye disease is a common ocular surface disease in patients who are undergoing cataract surgery. The significance of dry eye disease is often underestimated or overlooked during preoperative assessment of cataract. We report an 80-year-old patient, with a background of seropositive rheumatoid arthritis and diabetes, who presented with an acute corneal melt and perforation associated with undiagnosed dry eye disease and use of topical ketorolac 1 week following an uncomplicated cataract surgery. The patient underwent repeated corneal gluing for corneal perforation and was subsequently diagnosed and treated for bilateral moderate-severe dry eye disease. This case highlights the importance of meticulous preoperative assessment and management of the ocular surface, especially in patients with systemic diseases such as rheumatoid arthritis and diabetes prior to cataract surgery. The implication of the use of topical nonsteroidal anti-inflammatory drugs following cataract surgery - which might have contributed to the process of corneal melt in our case - is also discussed.

Three cases of acute sterile corneal melt after cataract surgery

Purpose

To report three cases of acute sterile corneal melt after cataract surgery.

Observations

Case 1 was a 21-year-old male presenting with a corneal perforation of his right eye at 10 days after cataract surgery. Case 2 was a 67-year-old male who developed a corneal melt in his left eye at 15 days after cataract surgery. Case 3 was a 70-year-old female with a corneal melt of her left eye at 7 days after cataract surgery. None of the cases exhibited any signs of infection. Topical nonsteroidal anti-inflammatory drug use, dry eye, systemic autoimmune diseases, and/or a combination of these were present in patients who developed corneal melt after cataract surgery.

Conclusions and Importance

Corneal melt cases can occur early after cataract surgery, thereby leading to corneal thinning and perforation.

Potential for endocannabinoid system modulation in ocular pain and inflammation: filling the gaps in current pharmacological options

Challenges in the management of ocular pain are an underappreciated topic. Currently available therapeutics lack both efficacy and clear guidelines for their use, with many also possessing unacceptable side effects. Promising novel agents would offer analgesic, anti-inflammatory, and possibly neuroprotective actions; have favorable ocular safety profiles; and show potential in managing neuropathic pain. Growing evidence supports a link between the endocannabinoid system (ECS) and a range of physiological and disease processes, notably those involving inflammation and pain. Both preclinical and clinical data suggest analgesic and anti-inflammatory actions of cannabinoids and ECS-modifying drugs in chronic pain conditions, including those of neuropathic origin. This review will examine existing evidence for the anatomical and physiological basis of ocular pain, specifically, ocular surface disease and the development of chronic ocular pain. The mechanism of action, efficacy, and limitations of currently available treatments will be discussed, and current knowledge related to ECS-modulation of ocular pain and inflammatory disease will be summarized. A perspective will be provided on the future directions of ECS research in terms of developing cannabinoid therapeutics for ocular pain.

Cataract surgery and nonsteroidal antiinflammatory drugs

Nonsteroidal antiinflammatory drugs (NSAIDs) have become an important adjunctive tool for surgeons performing routine and complicated cataract surgery. These medications have been found to reduce pain, prevent intraoperative miosis, modulate postoperative inflammation, and reduce the incidence of cystoid macular edema (CME). Whether used alone, synergistically with steroids, or for specific high-risk eyes prone to the development of CME, the effectiveness of these medications is compelling. This review describes the potential preoperative, intraoperative, and postoperative uses of NSAIDs, including the potency, indications and treatment paradigms and adverse effects and contraindications. A thorough understanding of these issues will help surgeons maximize the therapeutic benefits of these agents and improve surgical outcomes.

FINANCIAL DISCLOSURE

Proprietary or commercial disclosures are listed after the references.

A randomized controlled trial comparing the efficacy of topical antibiotic steroid combination versus no treatment after fornix-incision strabismus surgery

PURPOSE

To compare comfort and inflammation in patients treated with postoperative topical antibiotic steroids in one eye versus no treatment in the other eye.

METHODS

This prospective, randomized single-masked study included all patients with planned symmetrical strabismus surgery via fornix incision. One eye was randomly assigned to topical postoperative tobramycin-dexamethasone and the other eye was not treated. Patient and parent questionnaires were administered, and two masked observers assessed conjunctival injection over the muscle and wound site.

RESULTS

A total of 70 patients completed at least 1 postoperative visit and were included. There was no statistically significant difference between the treatment eye and the no treatment eye in any of the studied parameters.

CONCLUSIONS

Postoperative topical antibiotic steroid did not prove to be superior to no treatment in uncomplicated fornix surgery with regard to patient comfort and inflammation. In those cases, consideration may be given to sparing the patient the inconvenience, cost, and potential complications of the topical medication.

Efficacy of addition of nepafenac 0.1% to steroid eye drops in prevention of post-phaco macular edema in high-risk eyes

Purpose:

To compare the efficacy of addition of nonsteroidal anti-inflammatory eye drops to steroidal eye drops with that of using postoperative steroidal anti-inflammatory eye drops alone in prevention of macular edema in high-risk patients.

Setting:

Cairo University Hospital.

Design:

This study was comparative prospective interventional randomized study.

Methods:

This study included 100 cataractous eyes divided into five subgroups: 20 eyes of diabetic patients, 20 uveitic eyes, 20 traumatic cataracts, 20 glaucomatous eyes on topical prostaglandin analogs, and 20 eyes with posterior capsular rupture during phacoemulsification. Each subgroup of 20 was randomized between two groups of 10 eyes, group A received postoperative topical steroids alone and group B received both steroidal and nonsteroidal anti-inflammatory eye drops.

Results:

There was significant increase in postoperative central foveal thickness as compared to preoperative values in both groups (60.9 ± 87.95 µ in group A and 25.52 ± 57.26 µ in group B) that was significantly more in group A (P value 0.016). There was significant difference in postoperative macular thickness between both groups (280.1 ± 86.0 µ and 246.80 ± 57.73 µ, respectively, in groups A and B) (P value = 0.012). There was no statistically significant difference between both groups in preoperative and postoperative corrected distance visual acuity and intraocular pressure.

Conclusion:

Addition of topical nepafenac eye drops to topical steroid drops significantly reduced the amount of pseudophakic macular edema after cataract surgery in high-risk eyes.

Phosphosulindac is efficacious in an improved concanavalin A-based rabbit model of chronic dry eye disease

Dry eye disease (DED) currently has no satisfactory treatment partly because of the lack of informative animal models. We evaluated the anti-inflammatory phosphosulindac (PS) for the treatment of DED using a new rabbit model of DED based on the concanavalin A (Con A) acute DED model: we injected all lacrimal glands with Con A weekly under ultrasound guidance, which prolonged DED to >3 weeks, and thoroughly assessed efficacy with tear break-up time (TBUT), tear osmolarity, Schirmer test, and tear lactoferrin levels. Rabbits with DED (n = 8-10 eyes per group) were treated topically with PS or vehicle 3×/day for 21days. PS restored TBUT, tear osmolarity, and lactoferrin levels (P < 0.0001-0.04) to normal but did not significantly improve the results of the Schirmer test. PS showed no side effects and was much more efficacious than cyclosporine or lifitegrast. In the cornea, PS suppressed the activation of nuclear factor kappa-B, the levels of transforming growth factor beta, interleukin-1 beta, interleukin-6, and interleukin-8, and the levels of matrix metalloproteinase (MMP)-1 and MMP-9, and MMP activity. Levels of prostaglandin E₂ (PGE₂) in tears and cornea were preserved in PS-treated rabbits. Ketorolac and diclofenac, two ophthalmic NSAIDs causing corneal melt, nearly completely suppressed PGE₂ levels but had no effect on MMPs. The effects of PS on PGE₂ and MMPs likely account for its apparent ocular safety. Our results establish an animal model for acute and chronic DED suitable for drug efficacy studies and indicate that PS merits evaluation for DED.

A Case of Allergic Urticaria After Ophthalmic Nepafenac Use

A 21-year-old male patient with no history of systemic disease or drug use presented to our clinic with redness and pain in the right eye. Best corrected visual acuity was 20/20 in both eyes. Inflamed pinguecula was observed on slit-lamp examination and the patient was prescribed ophthalmic nepafenac eye drops. After instilling the drops that day and the next day, the patient presented again due to pruritus and rash. Upon consultation with the dermatology department, the patient was diagnosed with drug-induced allergic urticaria and the nepafenac drops were discontinued. Although urticaria has been reported as a side effect after systemic non-steroidal anti-inflammatory drug (NSAID) use, such a reaction has not been reported with an ophthalmic NSAID and ours is the first reported case of urticaria following ophthalmic nepafenac use. This unique case highlights the fact that ophthalmologists must also keep urticaria in mind as a potential side effect when prescribing this drug.

Conjunctival Goblet Cell Density Following Cataract Surgery With Diclofenac Versus Diclofenac and Rebamipide: A Randomized Trial

PURPOSE

To determine the effects of topical diclofenac or betamethasone with concomitant application of topical rebamipide on the conjunctival goblet cell density in eyes after cataract surgery.

DESIGN

Randomized clinical trial.

PARTICIPANTS

Eighty patients who were scheduled for cataract surgery.

METHODS

Patients were randomized into 4 groups according to the postoperative topical drugs to be given; Group A, diclofenac alone; Group B, diclofenac and rebamipide; Group C, betamethasone alone; and Group D, betamethasone and rebamipide. Impression cytology was performed before and at 1 month after the surgery, and the mean density of goblet cells was determined.

RESULTS

The mean (± SD) density of goblet cells before the surgery in Group A was 257.0 ± 188.7 cells/mm², and it decreased significantly to 86.5 ± 76.7 cells/mm² at 1 month after the surgery (P = .002). In Group B, the goblet cell density was not statistically different between before (238.5 ± 116.6 cells/mm²) and at 1 month after the surgery (211.3 ± 184.4 cells/mm², P = .55). In Groups C and D, the mean density of goblet cells was decreased at 1 month after the surgery, but the decreases were not significant (P = .11 and P = .52, respectively).

CONCLUSION

After cataract surgery with postoperative topical diclofenac, the conjunctival goblet cell density was significantly reduced, and this reduction was blocked by the concomitant use of topical rebamipide. These results suggest that the concomitant use of topical rebamipide with nonsteroidal anti-inflammatory drugs is beneficial, especially in cases with postoperative dry eyes.

Stromal lenticule transplantation for management of corneal perforations; one year results

PURPOSE

To study application of stromal lenticules extracted by femtolaser small incision lenticule extraction (SMILE) surgery as a surgical adjuvant to seal corneal perforations.

METHODS

Corneal stromal lenticules obtained through SMILE surgery with central thickness 100 μm or more were fixed over corneal perforation sites using 10-0 nylon interrupted stitches with an overlying single layer of amniotic membrane. Seven patients who had been followed up for a minimum of 12 months were assessed using slit-lamp biomicroscopy, fluorescein stain, tonometry, and best spectacle-corrected visual acuity (BSCVA) measurements. Postoperative complications were recorded throughout the follow up period.

RESULTS

Corneal perforations had successfully been sealed in all 7 patients; 3 patients (42.9%) exhibited improved postoperative BSCVA. During the follow-up period of one year, no signs of re-perforation or infections were detected in any patient.

CONCLUSIONS

These early findings suggest that the use of corneal stromal lenticules could be a safe and efficient surgical adjuvant for corneal perforation closure with potential clinical application, together with amniotic membrane, as relatively simple and low cost temporary measures to prepare perforated corneas for further definitive procedures.

Cystoid macular edema associated with iridocorneal endothelial syndrome: a case report

BACKGROUND

Iridocorneal endothelial (ICE) syndrome occurs mainly in young and middle-aged women and typically presents as a unilateral disease characterized by abnormalities of the iris and corneal endothelium. While the ICE syndrome is known to be associated with glaucoma and bullous keratopathy, to our knowledge, only two cases of ICE syndrome complicated with cystoid macular edema (CME) have been reported to date. In this paper, we report a case of ICE syndrome complicated with CME treated at our institution.

CASE PRESENTATION

The subject was a 51-year-old woman. In October 2013, she was examined by a primary care physician for blurred vision in her left eye. Dyscoria and abnormality of the corneal endothelium were observed, and the patient was diagnosed with ICE syndrome. In November of the same year, she was referred to our institution with a decrease in visual acuity and CME, both in her left eye. At initial examination, her best corrected decimal visual acuity was 1.0 (Snellen equivalent: 20/20) in the right eye and 0.5 (20/40) in the left eye. Intraocular pressure was 12 mmHg in both eyes. She was diagnosed with Cogan-Reese syndrome based on marked ectropion uveae, peripheral anterior synechia, and abnormalities of the corneal endothelium. Marked CME was observed on ophthalmoscopy and optical coherence tomography. A topical non-steroidal anti-inflammatory drug (nepafenac 0.1 %) was applied to the left eye four times daily from January 2014. Four weeks later, the CME had resolved and her visual acuity was 1.0 (20/20).

CONCLUSION

While non-steroidal anti-inflammatory drugs and steroids did not appear to be effective in two previously reported cases of ICE syndrome complicated with CME, topical nepafenac was effective in this case. However, more such cases are needed before concluding that topical nepafenac is effective in this situation.

Mechanisms and management of dry eye in cataract surgery patients

PURPOSE OF REVIEW

To provide a summary of the mechanisms that may cause dry eye after cataract surgery and discuss available and upcoming treatment modalities.

RECENT FINDINGS

Development or worsening of dry eye symptoms after cataract surgery is multifactorial with corneal nerve transection, inflammation, goblet cell loss, and meibomian gland dysfunction commonly cited as underlying disorders. With increasing awareness of the prevalence of dry eye disease, current surgical techniques are being analyzed for their contribution to the issue. Although many classic interventions, such as artificial tears and anti-inflammatory drops, remain first-line treatment options, they may not adequately address abnormalities of the tear film. The trend has been to create new drugs and technologies that target meibomian gland deficiencies and restore goblet cell numbers.

SUMMARY

Therapy for postoperative dry eye symptoms should be determined based on symptom severity and which underlying cause is most prominent at a given time. Patients with high-level risk factors for dry eye should be evaluated preoperatively to determine whether they have preexisting dry eye disease or if they are susceptible to developing disease after surgery.

Corneal Melting after Collagen Cross-Linking for Keratoconus in a Thin Cornea of a Diabetic Patient Treated with Topical Nepafenac: A Case Report with a Literature Review

PURPOSE

To report the case of a 50-year-old woman with diabetes that presented with corneal melting and perforation 6 weeks after collagen cross-linking (CxL) for keratoconus (KC) and postoperative use of nepafenac eye drops, a nonsteroidal anti-inflammatory drug (NSAID).

METHODS

This is a case report of a patient with diabetes, KC and a thin cornea that had undergone left eye corneal CxL at a different hospital followed by postoperative use of nepafenac eye drops for 6 weeks.

RESULTS

The patient presented for the first time to our clinic with left corneal melting, perforation and iris prolapse 6 weeks after corneal CxL and topical nepafenac use. She was treated with a left eye tectonic penetrating keratoplasty, extracapsular cataract extraction, intraocular lens implantation and pupilloplasty.

CONCLUSIONS

The corneal melting and perforation in this patient was associated with multiple risk factors: (1) nepafenac eye drop use, (2) CxL in a cornea thinner than 400 µm and (3) diabetes. The recommended corneal thickness limits should be respected. Topical NSAIDs should be used with caution if used as postoperative treatment after corneal CxL and in patients with diabetes, epithelial defect or delayed healing, because of the possible increased risk for corneal melting when multiple risk factors are observed.

Cataract surgery in chronic Stevens-Johnson syndrome: aspects and outcomes

AIM

To assess the outcome of cataract surgery in patients with chronic sequelae of Stevens-Johnson syndrome (SJS).

METHODS

Setting: Tertiary eye care centre in South India.

DESIGN

Retrospective, non-comparative, consecutive, interventional case series. Study period: March 2003 to May 2014. Of the 1662 consecutive patients with SJS, 32 patients (40 eyes) with chronic sequelae of SJS who underwent cataract surgery were included. The main outcome measures were best-corrected visual acuity (BCVA) and ocular surface stabilisation. The visual acuity was expressed with reference to the logMAR.

RESULTS

The study included 12 men (37.5%) and 20 women (62.5%). 8 patients (25%) had bilateral cataract surgeries. The median preoperative BCVA was 1.61 (IQR, 0.80 to 2.78) (only perception of light in three eyes). The median BCVA in the immediate postoperative period was 0.60 (IQR, 0.30 to 1.48) (perception of light in an eye) which was significantly different from the preoperative BCVA (p<0.0001). The median BCVA achieved was 0.30 (IQR, 0.00 to 0.80), suggesting further improvement. Median time taken to achieve this postoperatively was 1.5 months (IQR, 8 days to 3 months). The median BCVA during the last follow-up was 0.48 (IQR, 0.18 to 1.00). The preferred type of cataract surgery was phacoemulsification. Ocular surface condition remained stable in 35 eyes (87.5%). Ocular surface breakdown in four eyes (10%) was managed appropriately.

CONCLUSION

Cataract surgery outcome can be visually rewarding in chronic sequelae of SJS provided ocular surface integrity is adequately maintained preoperatively and postoperatively.

One-Day Use of Preoperative Topical Nonsteroidal Anti-Inflammatory Drug Prevents Intraoperative Prostaglandin Level Elevation During Femtosecond Laser-Assisted Cataract Surgery

PURPOSE

To determine if pretreatment with topical nonsteroidal anti-inflammatory drug (NSAID) prior to femtosecond laser-assisted cataract surgery (FLACS) prevents intraoperative prostaglandin level elevation as a potential risk factor of postoperative complications.

PATIENTS AND METHODS

Thirty-six patients with clinically significant cataract and without any concomitant general or ophthalmic disease were enrolled into the three age-matched groups of the study. The mean age of the patients was 62.3 ± 13.1 years. The first group of patients underwent traditional phacoemulsification (Control group), on the second group of patients FLACS was performed, and the third group of patients received topical 0.1% nepafenac pretreatment for 1one day prior to FLACS. Before the phacoemulsification part of the cataract surgery, approximately 110 µL of aqueous humor was collected in all groups. Total prostaglandin concentrations of the collected aqueous humor samples were evaluated by enzyme immunoassay (EIA).

RESULTS

The mean of the total prostaglandin concentrations of the aqueous humor samples was 208.8 ± 140.5 pg/mL in patients in the control group, 1449.1 ± 1019.7 pg/mL in the FLACS group (p > 0.001), and 92.2 ± 51.7 pg/mL in the group pretreated with topical NSAID before the FLACS (p > 0.001 compared to FLACS; p > 0.01 compared to control), respectively.

CONCLUSIONS

FLACS surgery increases intracameral prostaglandin concentration. However, using preoperative 1-day-long nonsteroid anti-inflammatory drops prior to FLACS, this intraoperative increase diminishes. Our study raises the possibility that NSAID pretreatment may be routinely administered before FLACS cataract surgeries to achieve a further decrease in the potential complications of increased total prostaglandin concentration during FLACS surgeries.

Ocular safety comparison of non-steroidal anti-inflammatory eye drops used in pseudophakic cystoid macular edema prevention

Non-steroidal anti-inflammatory drug (NSAID) eye drops are widely used to treat ocular inflammatory conditions related to ophthalmic surgical procedures, such as pseudophakic cystoid macular edema, and they have been used for off-label treatments. The most commonly used NSAIDs are diclofenac and ketorolac and the new molecules bromfenac and nepafenac have also been used. We used primary human keratocytes in cell culture in combination with a novel technology that evaluates dynamic real-time cytotoxicity through impedance analysis. This study also included classic cell viability tests (WST-1(®) and AlamarBlue(®)), wound healing assay, Hen's Egg Test and an ex vivo histopathological assay. NSAIDs were shown to have important cytotoxicities and to retard the healing response. Furthermore, the new eye drops containing bromfenac and nepafenac were more cytotoxic than the more classical eye drops. Nevertheless, no immuno-histochemical changes or acute irritation processes were observed after the administration of any eye drops tested. Due to cytotoxicity and the total absence of discomfort and observable injuries after the administration of these drugs, significant corneal alterations, such as corneal melts, can develop without any previous warning signs of toxicity.

Intravitreal triamcinolone acetonide in the treatment of ophthalmic inflammatory diseases with macular edema: a meta-analysis study

PURPOSE

To perform a meta-analysis of randomized controlled trials (RCTs) that compared the effects of treatment with intravitreal injections of triamcinolone acetonide (TA) with the standard of care for ocular inflammatory diseases.

METHODS

Medline database was searched for causes of macular edema terms in association with intravitreal triamcinolone. The primary outcome of interest included changes in best corrected visual acuity (BCVA) and central macular thickness (CMT). Pooled summary estimates for primary outcomes were calculated as weighted mean differences (WMD) either on a fixed- or random-effect model.

RESULTS

A total of 8 studies were included for quantitative analysis. Treatment with intravitreal TA showed improvement in BCVA compared with standard of care at 1 month (WMD, -0.09; 95% confidence interval [CI], -0.17 to -0.02), at 4 months (WMD, -0.09; 95% CI, -0.15 to -0.03), at 6 months (WMD, -0.13; 95% CI, -0.21 to -0.05), and in CMT at 1 month (WMD, -88.14; 95% CI, -105.86 to -70.43). Increased intraocular pressure (IOP) among patients treated with intravitreal TA was found at 4 months (WMD, 2.83; 95% CI, 1.96 to 3.70), persisting also at 12 months (WMD, 3.78; 95% CI, 2.97 to 4.59), compared with those receiving the standard of care. All outcomes are mostly equivalent at further follow-up times.

CONCLUSIONS

Intravitreal injections of TA may offer certain advantages over the standard of care for ocular inflammatory diseases, especially in the early stage of follow-up. However, it is necessary to take into account risks and benefits of TA treatment for ocular inflammatory diseases due to possible ocular hypertension elicited, in general, by intravitreal injection of corticosteroids.

Cataract surgery in patients with ocular surface disease: An update in clinical diagnosis and treatment

In this article we review essentials of diagnosis and management of ocular surface disease in patients who undergo cataract surgery. It is clearly shown that dry eye disease worsens following the cataract surgery in patients with prior history of ocular surface disease, Also new cases of dry eye might appear. Current strategies for the timely diagnosis and proper management of dry eye syndrome in the face of cataract surgery patients are mainly emphasized. To achieve the best outcome in cataract surgery, a healthy ocular surface is crucial. While ocular surface preparation is indispensable in patients with established ocular surface disease, it is also helpful in those with minimal signs or symptoms of surface disease. The current approach begins with early diagnosis and drastic management of ocular surface disease before cataract surgery using a stepwise regimen customized to each patient and disease severity. These measures are continued throughout and after the surgery.

Toxic epitheliopathy from a single application of preservative free oxybuprocaine (0.4%) in a patient with Sjogren's syndrome

Topical ocular anaesthetic agents are frequently used for ophthalmic diagnosis and surgery. While corneal complications following long-term use or misuse of local anaesthetic solutions have been described, toxic epitheliopathy after a single application of six drops of preservative free oxybuprocaine is rare. In order to increase the awareness of this ocular complication, we report such a case in a patient with Sjogren's syndrome who presented for elective cataract surgery. We outline the mechanisms proposed to explain the ocular toxic effects of oxybuprocaine and discuss the management principles in preventing this complication in the context of Sjogren's syndrome.

Nepafenac: An Ophthalmic Nonsteroidal Antiinflammatory Drug for Pain After Cataract Surgery

OBJECTIVE:

To examine the efficacy of nepafenac in the treatment of pain and inflammation in patients after cataract surgery using evidence from controlled clinical studies.

DATA SOURCES:

Citations in Google Scholar, PubMed, and Web of Science from January 1, 2005, to March 25, 2013, were identified using nepafenac and cataract as search terms.

STUDY SELECTION AND DATA EXTRACTION:

The literature search was limited to human studies published in English. Three trials that compared nepafenac with other nonsteroidal antiinflammatory drugs (NSAIDs) were included.

DATA SYNTHESIS:

The pharmacokinetics and pharmacodynamics of nepafenac 0.1% suspension (and its active metabolite, amfenac) were compared with bromfenac 0.09% solution and ketorolac 0.4% solution with respect to aqueous humor concentrations and ability to reduce cyclooxygenase 1 and 2 (COX-1 and COX-2) enzymes. The maximum concentration (Cmax) values of ketorolac and amfenac were statistically similar, while the Cmax of bromfenac was significantly lower than that of amfenac. Ketorolac most effectively inhibited COX-1 enzymes; COX-2 enzymes were most effectively reduced by amfenac. When nepafenac 0.1% suspension was compared with placebo and ketorolac 0.5% solution, nepafenac achieved a higher percentage cure rate than placebo at day 14 (p = 0.0241). Significant differences in cure rates between nepafenac and ketorolac were not observed. Nepafenac 0.1%, bromfenac 0.09%, and ketorolac 0.45% were compared to determine which most effectively reduced prostaglandin E2 (PGE2) following surgery. PGE2 concentrations were significantly lowest in the ketorolac group, followed by the bromfenac and nepafenac groups, respectively. Topical nepafenac 0.1% suspension was approved in 2005. A 0.3% suspension was approved in October 2012. The 0.3% product may have some advantages over its predecessor: it is dosed once rather than thrice daily, which may increase patient adherence and improve outcomes. The price and dosing frequency of the 0.3% product are comparable to those of bromfenac 0.09% solution.

CONCLUSIONS:

The 2 nepafenac products appear to be equally efficacious, with a slightly increased adverse event rate in patients using the 0.3% versus 0.1% formulation. Head-to-head clinical trials that compare the 0.3% product with the 0.1% product or other commercially available NSAIDs are unavailable.

Cataract surgery in the face of ocular surface disease

PURPOSE OF REVIEW

This article reviews the importance of ocular surface management in patients undergoing cataract surgery. The current strategies for the diagnosis and management of ocular surface disease in cataract surgery patients are discussed.

RECENT FINDINGS

The current trend is to diagnose and treat ocular surface disease before cataract surgery using a stepwise regimen tailored to the individual patient and disease severity.

SUMMARY

Maintaining a healthy ocular surface is essential for achieving the best visual outcome in cataract patients. Ocular surface preparation is beneficial not only in patients with established ocular surface disease, but also in those with minimal signs or symptoms of surface disease.

Topical ophthalmic NSAIDs: a discussion with focus on nepafenac ophthalmic suspension

The removal of diclofenac sodium ophthalmic solution as a viable pharmaceutical entity in September 1999 from the US market spurred considerable interest in the general safety and effectiveness of topical ophthalmic NSAIDs for treatment of anterior segment inflammation. In late 1999 the use of topical ocular NSAIDs declined in the US as a result of incidents involving corneal melts and toxicity surrounding use of generic diclofenac. However, since the removal of diclofenac sodium ophthalmic solution from the marketplace, ophthalmic NSAIDs have regained use as viable pharmacotherapeutic entities. Moreover, several new ophthalmic NSAID products have recently been introduced for commercial use in the US including the novel chemical entity nepafenac. The purpose of this report is to revisit the use of topical ophthalmic NSAIDs for the treatment of surgically induced anterior segment inflammation with a particular focus on nepafenac. Nepafenac is unique among ophthalmic NSAIDs in that it is a prodrug deaminated to amfenac, a highly effective non-selective cyclooxygenase inhibitor. In the case of topical ophthalmic NSAIDs, practitioners should carefully weigh the cost-benefit of implementing “highly potent” new drug products because perturbations in pharmacodynamic response due to the inherent novelty in terms of chemical designs may outweigh the demonstrated replicative pharmacologic action of all topical ophthalmic NSAIDs.

Central corneal melting associated with reformulated generic diclofenac in a patient with inferior fornix foreshortening

Purpose

To report a case of corneal melting in a patient with fornix foreshortening being treated with reformulated generic diclofenac.

Methods

Case report.

Results

An asymptomatic 76-year old man presented with central corneal melting while being treated with reformulated generic diclofenac. This formulation did not contain the vitamin E derivative, tocophersolan, which has been felt to contribute to corneal melting associated with generic diclofenac in the past. Other factors for corneal melting included multiple medication use and altered forniceal architecture, but did not include previous corneal or cataract surgery. Following discontinuation of the topical medications and temporary tarsorrhapy, the defect reepithelialized.

Conclusion

In patients with a compromised ocular surface, reformulated generic diclofenac has the potential to cause corneal melting without prior cataract or refractive surgery. Use should not be indiscriminate or without close supervision.

Nonsteroidal anti-inflammatory drugs in ophthalmology

Nonsteroidal anti-inflammatory drugs (NSAIDs) are increasingly employed in ophthalmology to reduce miosis and inflammation, manage scleritis, and prevent and treat cystoid macular edema associated with cataract surgery. In addition, they may decrease postoperative pain and photophobia associated with refractive surgery and may reduce the itching associated with allergic conjunctivitis. In recent years, the U.S. Food and Drug Administration has approved new topical NSAIDs, and previously approved NSAIDs have been reformulated. These additions and changes result in different pharmacokinetics and dosing intervals, which may offer therapeutic advantages. For example, therapeutic effects on diabetic retinopathy and age-related macular degeneration may now be achievable. We provide an updated review on NSAIDs and a summary of their current uses in ophthalmology with attention to potential future applications.

Effect of topical 0.5% morphine on postoperative pain after photorefractive keratectomy

PURPOSE

To investigate safety and efficacy of 0.5% morphine drops for pain control after photorefractive keratectomy (PRK).

METHODS

In a double-blind prospective study, 40 patients were randomized to either 0.5% morphine drops (n=20) or vehicle control (n=20). Treatment occurred every 2 hours following PRK on the day of the procedure, then four times daily on postoperative days 1 through 3. Patients completed pain assessment questionnaires (visual descriptor, numerical rating, visual analog scales, and oral analgesic consumption) every 2 hours while awake during the treatment period. Daily average and maximum scores were compared between the two groups. Patients were examined daily for 4 days after PRK, weekly for 4 weeks, then monthly for 3 months. Epithelial healing, corneal haze, and refractive outcomes were compared.

RESULTS

Both average and maximum pain scores were lower in the morphine group than in the vehicle control group on all scales and during all 4 days after PRK. Statistical significance (P<.05) was reached on numeric rating scale on procedure day and on postoperative day 1. The difference between the groups on the visual analog scale was statistically significant on procedure day, and on postoperative days 1 and 2. Oral analgesic consumption was higher in the vehicle control group on postoperative day 2. No difference between groups was noted in epithelial healing or refractive outcomes. Stromal haze scores were lower in the morphine group, but the difference was not statistically significant.

CONCLUSIONS

Topical 0.5% morphine may be an effective and safe method of pain control after PRK.

Management of ocular inflammation and pain following cataract surgery: focus on bromfenac ophthalmic solution

Recently, several new ophthalmic NSAID products have been introduced for commercial use in the United States. The purpose of this review is to briefly overview the ophthalmic NSAIDs currently in use and to discuss the management of postoperative ocular inflammation and pain following cataract surgery with a particular focus on bromfenac ophthalmic solution 0.09%. Bromfenac ophthalmic solution 0.09% is indicated for the reduction of ocular pain and inflammation following cataract surgery. Studies have shown that bromfenac ophthalmic solution 0.09% has equivalent efficacy to the other topical NSAIDs in reducing postsurgical inflammation and controlling pain. The unique chemical structure of bromfenac makes it both a potent inhibitor of the COX-2 enzyme and a highly lipophilic molecule that rapidly penetrates to produce early and sustained drug levels in all ocular tissues. Clinically, these pharmacokinetic features are manifested in a rapid reduction of postsurgical inflammation and pain with bid dosing. Bromfenac ophthalmic solution 0.09% is a versatile agent and is effective when used as either monotherapy or as an adjunct therapy to steroids.

Corneal melt in lattice corneal dystrophy type II after cataract surgery

We report a patient with lattice corneal dystrophy type II, also known as Meretoja syndrome or familial amyloidosis Finnish type, who developed a corneal melt 15 days after uneventful phacoemulsification. Despite conservative treatment, the corneal melt resulted in perforation. Uneventful penetrating keratoplasty was performed, but delayed graft epithelial healing was noticed postoperatively. Corneal button histopathological evaluation confirmed the initial clinical diagnosis. To our knowledge, this is the first reported case of corneal melt and perforation in a patient with lattice corneal dystrophy type II.

Current awareness: Pharmacoepidemiology and drug safety

In order to keep subscribers up‐to‐date with the latest developments in their field, John Wiley & Sons are providing a current awareness service in each issue of the journal. The bibliography contains newly published material in the field of pharmacoepidemiology and drug safety. Each bibliography is divided into 20 sections: 1 Reviews; 2 General; 3 Anti‐infective Agents; 4 Cardiovascular System Agents; 5 CNS Depressive Agents; 6 Non‐steroidal Anti‐inflammatory Agents; 7 CNS Agents; 8 Anti‐neoplastic Agents; 9 Haematological Agents; 10 Neuroregulator‐Blocking Agents; 11 Dermatological Agents; 12 Immunosuppressive Agents; 13 Autonomic Agents; 14 Respiratory System Agents; 15 Neuromuscular Agents; 16 Reproductive System Agents; 17 Gastrointestinal System Agents; 18 Anti‐inflammatory Agents ‐ Steroidal; 19 Teratogens/fetal exposure; 20 Others. Within each section, articles are listed in alphabetical order with respect to author. If, in the preceding period, no publications are located relevant to any one of these headings, that section will be omitted.