Topical naproxen sodium for inhibition of miosis during cataract surgery. Prospective, randomized clinical trials

Efficacy of Nepafenac versus Flurbiprofen in Maintaining Intraoperative Mydriasis During Phacoemulsification: A Comparative Study

Purpose

To compare the efficacy of topical nepafenac (0.1%) with flurbiprofen (0.03%) in maintaining intra-operative mydriasis during phacoemulsification surgery.

Patients and Methods

This study comprised of 160 patients, who were divided into two arms of 80 each (arms A and B) after randomisation. Pre-operatively, all patients received one drop of tropicamide 0.8% and phenylephrine 5% (combination), 4 times, at an interval of 15 minutes on the day of surgery. Thereafter, Nepafenac drop in arm A/Flurbiprofen drop in arm B was administered 4 times, at an interval of 15 minutes keeping a gap of 10 minutes between tropicamide-phenylephrine and any of the experimental drugs. Phacoemulsification was performed one hour after the administration of last drop. Both vertical and horizontal pupillary diameter were measured at three steps; immediately before the surgical incision (baseline), at the end of emulsification of nucleus (before irrigation and aspiration) and at the end of surgery (after stromal hydration).

Results

The difference in pupillary diameter between two groups, was statistically insignificant for vertical diameter (P = 0.08) and horizontal diameter (P = 0.28) at the start of surgery. On the other hand, pupillary diameter difference was statistically significant after emulsification of nucleus and at the end of surgery as well when both vertical (P < 0.05) and horizontal diameter (P < 0.05) were considered. The total reduction in pupillary diameter (both vertically and horizontally) was significantly less in the Nepafenac as compared to Flurbiprofen group (P < 0.05). Analysis of mean cumulative dissipated energy did not document any appreciable difference between the two groups. Phacoemulsification time analysis yielded statistically significant results (P = 0.004) between the Nepafenac and Flurbiprofen group.

Conclusion

In the present study, topical Nepafenac (0.1%) proved to be more efficacious in maintaining intra-operative mydriasis during phacoemulsification surgery as compared to topical Flurbiprofen (0.03%).

Additive Effect of Topical Nepafenac on Mydriasis in Patients With Diabetes Mellitus

OBJECTIVES

To evaluate the additive effect of topical nepafenac on pupil diameter (PD) in patients with diabetes mellitus (DM) and cataract.

METHODS

This prospective comparative study included the patients having cataract surgery with and without DM. Two consecutive PD measurements were taken using an automatic quantitative pupillometry system (MonPack One, Metrovision). A baseline measurement was taken, then one drop of nepafenac % 0.1 (Nevanac; Alcon, Fort Worth, TX) was instilled only to the eye that will be operated on (study eye). Cyclopentolate 1.0% (Sikloplejin; Abdi İbrahim, İstanbul, Turkey) was instilled to both eyes (study eye/fellow eye) 5 minutes later. The second measurement was taken at 1 hour after this application.

RESULTS

The DM group consisted of 43 patients, and the control group consisted of 39 participants. The baseline PDs of both eyes were similar in the DM group (P=0.070) and the control group (P=0.345). The change in pupil size from baseline to mydriasis was statistically significantly greater in the study eyes (2.69±0.53) than fellow eyes (2.54±0.61) in the DM group (P=0.009), but there was no statistically significant difference in the control group (2.94±0.63 vs. 2.86±0.58). When the groups were compared, the PD changes were similar in the study eyes between groups (P=0.065), while the PD changes in the fellow eyes were lower in the DM group (P=0.017).

CONCLUSIONS

Nepafenac has been shown additive effect on pupil dilation in diabetic patients before cataract surgery.

Topical Nonsteroidal Anti-Inflammatory Drugs in Uncomplicated Cataract Surgery: Effect of Sodium Naproxen

Purpose

To investigate whether topical nonsteroidal anti inflammatory drugs (NSAIDs) are useful, in the absence of concomitant corticosteroid therapy, in limiting postoperative inflammation after uncomplicated cataract surgery.

Methods

A total of 328 patients were enrolled in a prospective, randomized, double-masked, parallel-group, active-controlled study. Anterior chamber inflammation (ACI) was evaluated as the primary efficacy parameter. Only patients with moderate inflammation (ACI score of ≤4) the day after surgery were randomized and treated with NSAIDs. A novel topical formulation containing 0.2% sodium naproxen was compared with 0.1% diclofenac. Both were administered three times a day for 14 consecutive days. Ocular inflammation was measured after 7 and 14 days by using slit-lamp biomicroscopy. Safety parameters were also evaluated at the same time.

Results

Both treatments were equally effective in controlling postsurgical inflammation. No statistically significant differences between treatment groups were observed for the safety variables. No serious adverse events (AEs) occurred during the course of the study. The most frequent AE reported with naproxen was eye redness.

Conclusions

NSAIDs can effectively be used without concurrent administration of corticosteroids to control postoperative inflammation after uncomplicated cataract surgery. In addition, naproxen ophthalmic solution may be considered a suitable alternative to the currently available NSAIDs.

Comparison of preoperative nepafenac (0.1%) and flurbiprofen (0.03%) eye drops in maintaining mydriasis during small incision cataract surgery in patients with senile cataract: A randomized, double-blind study

Aims:

This study compared the effectiveness of prophylactic administration of topical flurbiprofen 0.03% and nepafenac 0.1% in maintaining mydriasis during small incision cataract surgery (SICS).

Materials and Methods:

This study was a prospective, randomized, double-blind comparative study in adult cataract patients given topical flurbiprofen or nepafenac prior to SICS and capsular bag intraocular lens (IOL) implantation at a tertiary care hospital. Horizontal and vertical diameters of pupil were measured at the beginning and end of surgery, and the mean values were compared across the two groups. Unpaired t-test and Fisher's exact test were used to analyse the results.

Results:

A total of 70 eyes of cataract surgery patients, 33 males and 37 females, with a mean age of 58.5 ± 11.24 years, were included in the study. The mean horizontal and vertical diameters of the two groups were similar at the start of surgery. Significant differences were seen after IOL implantation, with the nepafenac group having the larger mean diameters in both horizontal (P = 0.03) and vertical (P = 0.04) pupillary measurements.

Conclusions:

Topical nepafenac has been shown to be a more effective inhibitor of meiosis during SICS and provides a more stable mydriatic effect compared to topical flurbiprofen.

Effect of air bubble on inflammation after cataract surgery in rabbit eyes

Purpose:

Intense inflammation after cataract surgery can cause cystoid macular edema, posterior synechia and posterior capsule opacification. This experimental study was performed to investigate the effect of air bubble on inflammation when given to anterior chamber of rabbit eyes after cataract surgery.

Materials and Methods:

30 eyes of 15 rabbits were enrolled in the study. One of the two eyes was in the study group and the other eye was in the control group. After surgery air bubble was given to the anterior chamber of the study group eye and balanced salt solution (BSS; Alcon) was left in the anterior chamber of control eye.

Results:

On the first, second, fourth and fifth days, anterior chamber inflammations of the eyes were examined by biomicroscopy. On the sixth day anterior chamber fluid samples were taken for evaluation of nitric oxide levels as an inflammation marker. When the two groups were compared, in the air bubble group there was statistically less inflammation was seen. (1, 2, 4. days P = 0,001, and 5. day P = 0,009).

Conclusions:

These results have shown that when air bubble is left in anterior chamber of rabbits’ eyes after cataract surgery, it reduced inflammation. We believe that, air bubble in the anterior chamber may be more beneficial in the cataract surgery of especially pediatric age group, uveitis patients and diabetics where we see higher inflammation. However, greater and long termed experimental and clinical studies are necessary for more accurate findings.

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.

Redilatation with intracameral mydriatics in phacoemulsification surgery

PURPOSE

To determine whether intracameral mydriatics can redilate pupils that contract during phacoemulsification cataract surgery.

METHODS

A total of 80 patients were included in this prospective, randomized, double-blind study performed at Ornsköldsviks Hospital Eye Clinic. Of these, 60 patients had 0.6 microg/ml of epinephrine added to the balanced salt solution (BSS) used for irrigation and 20 patients did not. The patients in each group were randomized and given either an intracameral mydriatics (ICM) solution or placebo intracamerally after phacoemulsification and cortex cleaning. The pupil size was registered preoperatively, after cortex cleaning, 30 seconds after study injection, 2 mins after study injection and the day after surgery.

RESULTS

No clinically relevant differences were found preoperatively. In the epinephrine material a significantly longer operation time (p = 0.023) and more procedures requiring Vision Blue and Kelman-type tip in the placebo group might indicate diversity in the grade of cataract. There was a greater degree of contraction in the absence of epinephrine in the irrigation solution (2.3 +/- 1.0 mm in the ICM group and 3.2 +/- 0.7 mm in the placebo group) compared to in the presence of epinephrine. With no epinephrine ICM significantly redilated the pupils at 30 seconds (p < or = 0.001) as well as at 2 mins (p = 0.015).

CONCLUSION

We have shown that in cases with an intraoperative pupil contraction, ICM is effective in redilating the pupil. Insufficient adrenergic stimulation of the pupil dilator appears to be a major factor causing intraoperative pupil contraction during phacoemulsification cataract surgery.

Engineered microcrystals for direct surface modification with layer-by-layer technique for optimized dissolution

This investigation relates to a two-step formulation development technique-synthesis of sterically stabilized drug microcrystals followed by direct surface modification by sequential electrostatic adsorption. Stable microcrystals of naproxen were produced by pH-induced reprecipitation in presence of a stabilizer. Sequential layer growth was achieved by the layer-by-layer assembly of biocompatible polyelectrolytes (PEs) and was registered using microelectrophoresis. The coated colloids were characterized using confocal laser scanning microscopy (CLSM) and scanning electron microscopy (SEM). The in vitro controlled release pattern of the drug through the PE diffusion barrier was studied using a diffusion cell assembly at physiological pH of 7.4, both before and after freeze-drying. Thermodynamically stable naproxen microcrystals were obtained by association and had a mean length of 15 microm and a zeta potential of -37.5 mV and were surface modified efficiently using biocompatible polysaccharide/protein-based PEs. Sufficient charge reversal with each layer was evident indicating layer growth with successive deposition cycles. The coating was complete and homogeneous as visualized under CLSM and SEM. The in vitro release study revealed that the stoichiometry of PEs in the complex coating and its molecular architecture played important roles in forming the diffusion barrier, which offered efficient control of the dissolution rate of drug core (up to 50% lower than bare crystal). The release profile fitted zero order release kinetics. This novel formulation technique enables administration of high concentrations of water-insoluble drugs in a stable, tissue compatible form, simultaneously affording sustained release.