Anti-inflammatory medication following cataract surgery: a randomized trial between preservative-free dexamethasone, diclofenac and their combination

Pseudophakic cystoid macular oedema and posterior capsular opacification rates after combined phaco-trabeculectomy vs. phaco alone

PURPOSE

To assess the risk for pseudophakic cystoid macular oedema (PCME) and posterior capsular opacification (PCO) associated with combined cataract surgery and trabeculectomy compared to cataract surgery alone.

METHODS

Data analysis of subjects who underwent routine cataract surgery without and with concomitant trabeculectomy at the Department of Ophthalmology, Bristol Eye Hospital, the UK, between January 2008 and December 2017. Odds ratios (ORs) for PCME between the types of surgeries were calculated using univariate and multivariate regression analysis. Multivariate Cox regression controlling for age and gender was used to estimate the hazard ratio (HR) for neodymium-doped yttrium aluminium garnet (Nd:YAG) laser capsulotomies.

RESULTS

This study included 56 973 cataract surgeries without and 288 with concomitant trabeculectomy (phaco-trab) with a mean follow-up time of 6.9 ± 4.2 years. Baseline variables (age and gender, diabetes, pseudoexfoliation, use of pupil expansion device and postoperative follow-up time) were comparable between the groups. Postoperative rates of PCME remained non-significant between the cataract surgery and phaco-trabe groups both in uni- and multi-variate analysis (OR 0.347, 95%CI 0.049-2.477, p = 0.291). Furthermore, in Cox regression analysis adjusted for the patients' age and gender, Nd:YAG laser capsulotomy rates remained non-significant between the cataract surgery and phaco-trabe groups (HR 1.250, 95%CI 0.883-1.769, p = 0.209).

CONCLUSIONS

In our large cohort study, combining trabeculectomy with cataract surgery did not predispose to an increased PCME or Nd:YAG laser capsulotomy rates.

Efficacy of the efficacy between dexamethasone versus triamcinolone acetonide after cataract surgery: A systematic review and meta-analysis

PURPOSE

To evaluate the clinical effects between dexamethasone and triamcinolone acetonide (TA) after phacoemulsification and intraocular lens implantation among cataract patients.

METHODS

Pubmed, Embase, and the Cochrane Library were searched for studies published up to August 2020. The primary outcome was intraocular pressure. The secondary outcomes were the logarithm of the minimum angle of resolution (logMAR), anterior chamber cell, and anterior chamber flare. The pooled effect sizes were expressed as weighted mean differences (WMDs) or standardized mean differences (SMDs) of 95% confidence intervals (95% CIs). Cochrane Collaboration risk of bias tool and Newcastle-Ottawa scale criteria were used for the quality assessment of included studies.

RESULTS

Seven relevant studies met the inclusion criteria. For the primary outcome, there was no significant difference between TA injection and dexamethasone in comparing intraocular pressure (IOP) (SMD = 0.22, 95% confidence interval [CI] [-0.29, 0.73], P = .408; I² = 86.9%) in the first day after treatment and last day of assessment. For the secondary outcomes, the logMAR (WMD = 0.01, 95% CI [-0.06, 0.08]) and the anterior chamber flare (SMD = 0.08, 95% CI [-0.01, 0.18], P = .087; I² = 0%) showed no differences. However, the amount of anterior chamber cells (SMD = -0.21, 95% CI [-0.42, -0.01], P = .044; I² = 0%) in the TA injection on the first day postoperative was higher than for dexamethasone. After treatment, there was no difference between the 2 groups.

CONCLUSIONS

This study supports that there were no differences in IOP, logMAR, and anterior chamber flare between TA injection and dexamethasone among cataract patients. TA injection treatment on the first day showed higher amounts of anterior chamber cells than with dexamethasone.

NSAIDs and Corticosteroids for the Postoperative Management of Age-Related Cataract Surgery: A Systematic Review and Meta-analysis

PURPOSE

To evaluate the safety and efficacy of non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids in the postoperative management of cataract surgery for age-related cataract in adults.

DESIGN

Meta-analysis.

METHODS

Cochrane, Embase, PubMed, Scopus, Web of Science and CINAHL were searched for articles using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) system. The review was registered prospectively with PROSPERO (CRD42022364733). Randomized controlled trials of patients undergoing age-related cataract surgery treated with corticosteroids, NSAIDs, or a combination were included.

RESULTS

A total of 19 studies were included, with 3473 patients (3638 eyes) treated following cataract surgery with NSAIDs (n = 1479), corticosteroids (n = 1307), or a combination (n = 687). Combination treatment demonstrated favorable best-corrected visual acuity compared to corticosteroids 4 to 6 weeks postoperatively (MD = -0.01 logMAR, 95% CI: -0.02, -0.01, I2 = 0%). NSAIDs had more favorable flare values than corticosteroids on day 7 (MD = -9.17 photons/ms, 95% CI = -16.52, -1.82, I2 = 94%), day 14 (MD = -5.23 photons/ms, 95% CI = -8.35, -2.11, I2 = 94%), and 4 to 6 weeks (MD = -1.62 photons/ms, 95% CI = -3.03, -0.20, I2 = 93%) postoperatively. Furthermore, 4 to 8 weeks postoperatively, patients treated with NSAIDs showed lower central macular thickness (MD = -13.26 µm, 95% CI = -18.66, -7.86, I2 = 81%) compared to those treated with corticosteroids. NSAIDs and combination treatment were associated with a lower incidence of central macular edema (OR = 0.16, 95% CI = 0.07, 0.35, I2 = 61%; OR = 0.21, 95% CI = 0.10, 0.45, I2 = 31%) than corticosteroids 4 to 8 weeks postoperatively.

CONCLUSIONS

NSAIDs and combination treatments could be regarded as more effective and safer alternatives to corticosteroids alone in the postoperative management of cataract surgery. Further studies should be conducted to determine why this evidence has not been reflected in practice patterns, and to further compare the effectiveness of NSAIDs and combination treatments.

Anti-inflammatory medication use after cataract surgery: online survey of practice patterns

PURPOSE

To determine current prescribing patterns for topical or intraocular/periocular anti-inflammatory medications (AIMs) after routine cataract surgery.

SETTING

kera-net online members.

DESIGN

Cross-sectional survey.

METHODS

An online survey was distributed to subscribers of kera-net, a global online platform sponsored by the Cornea Society. Questions were asked regarding the use of topical or intraocular/periocular AIM after cataract surgery and types of medications prescribed.

RESULTS

Of 217 surgeon respondents (23% response rate), 171 (79%) practiced in the United States and 171 (79%) were cornea subspecialists. Most of the respondents (n = 196, 97%) prescribed topical corticosteroids after routine cataract surgery. The most frequently prescribed were prednisolone acetate (n = 162, 83%), followed by dexamethasone (n = 26, 13%), difluprednate (n = 24, 12%), and loteprednol etabonate (n = 13, 7%). Corticosteroids comprised (n = 40, 32%) of total intraocular/periocular injections, with triamcinolone acetonide 10 or 40 mg (n = 19, 47.5%) most commonly used. 23 surgeons (58%) who utilized intraocular/periocular corticosteroids also prescribed topical corticosteroids. Topical nonsteroidal anti-inflammatory drugs were prescribed postoperatively by 148 surgeons (73%).

CONCLUSIONS

Most surgeons prescribed topical AIM after routine cataract surgery. Many surgeons injected intraocular or periocular AIM while prescribing topical AIM. The diversity of practice patterns may reflect the lack of clear evidence-based guidelines.

Assessment of the eye surface and subjective symptoms after using 0.1% dexamethasone drops with and without preservatives in patients after cataract surgery

Cataract surgery can cause dry eye symptoms. One of the many factors compromising the ocular surface is the use of benzalkonium chloride (BAC)-preserved topical eye drops administered during the postoperative period. In this open-label, prospective, randomized, comparative clinical trial, 40 patients not previously affected by dry eye disease were assigned to receive either preservative-free (PFD) or preserved (PD) dexamethasone 0.1% eye drops for two weeks after a standard phacoemulsification procedure. Fluorescein break-up time, ocular surface staining score, Schirmer test, Ocular Surface Disease Index and anterior chamber (AC) cells were evaluated at baseline prior to the surgery and 2 weeks after surgery. No statistically significant differences in baseline assessments were observed between groups. At week 2, a significant increase in corneal staining scores (p = 0.003) and foreign body sensation (p = 0.04) was observed for the PD group only. The conjunctival staining score was significantly higher in both groups. The mean AC cell grading was higher in the PFD group than in the PD group (0.28 ± 0.30 and 0.07 ± 0.18, respectively; p = 0.013). Preservative-free dexamethasone eye drops after cataract surgery caused milder dry eye symptoms as compared with preserved dexamethasone. The AC inflammation control comparison may require a larger study group. Trial registration: ClinicalTrials.gov identifier NCT05753787, 03/03/2023.

Early Inflammation Control After Trabeculectomy by Steroid and Non-steroidal Eye Drops: A Randomized Controlled Trial

INTRODUCTION

To compare the effect of three different anti-inflammatory regimens consisting of preservative-free dexamethasone (DEX), diclofenac (DICLO) eye drops, and their combination (DEX + DICLO) following trabeculectomy on early postoperative inflammation.

METHODS

A prospective randomized controlled trial. Sixty-nine patients undergoing trabeculectomy were randomized to receive either postoperative treatment with topical DEX (n = 23), topical DICLO (n = 23), or a combination of topical DEX and topical DICLO (n = 23) after trabeculectomy. The primary outcome was the anterior chamber flare measurement in the first 3 months postoperatively. Secondary outcomes included intraocular pressure, central corneal thickness, conjunctival injection, and number of cells in the anterior chamber from baseline to 3 months postoperatively.

RESULTS

Anterior chamber flare reached a maximum 1 day after trabeculectomy with an increase of 55% (95% CI 37-73%) for DEX, 64% (95% CI 47-82%) for DICLO, and 57% (95% CI 39-75%) for DEX + DICLO and returned to near pre-operative values 6 weeks after surgery. There were no significant differences in anterior chamber flare [effect size for DICLO: 0.16 (95% CI - 4.3 to 4.6), effect size for DEX + DICLO: 0.09 (95% CI - 4.1 to 4.3)], intraocular pressure, central corneal thickness, conjunctival injection, or number of cells in the anterior chamber between DEX, DICLO, or DEX + DICLO groups.

CONCLUSION

We found that topical diclofenac was not statistically different from topical dexamethasone in controlling early postoperative inflammation after trabeculectomy, while combining diclofenac and dexamethasone offered no added anti-inflammatory control compared to dexamethasone alone.

TRIAL REGISTRATION

www.

CLINICALTRIALS

gov (NCT04054830).

Factors influencing aqueous flare after cataract surgery and its evaluation with laser flare photometry

Despite the refinement of modern cataract surgery, postoperative inflammation still constitutes a substantial amount of visual morbidity worldwide. A surrogate for intraocular inflammation and blood-aqueous barrier breakdown can be objectively quantified by Laser flare photometry (LFP). This review outlines the utility of LFP in assessing the assessment of post-cataract surgery inflammation. It highlights the impact of preoperative pathological states such as uveitis and diabetes, intraoperative techniques, including efficient phacoemulsification and direct comparisons between postoperative anti-inflammatory regimes. There is a large interobserver variation in the subjective flare measurement after cataract surgery and the continued use of LFP amongst other objective, noninvasive measurements of intraocular inflammation, particularly in the further development of cataract surgery, is recommended.

Steroid Response after Trabeculectomy-A Randomized Controlled Trial Comparing Dexamethasone to Diclofenac Eye Drops

This prospective randomized controlled trial aimed to compare changes in intraocular pressure in three different anti-inflammatory regimens following trabeculectomy. Sixty-nine patients were randomized to receive either postoperative prophylaxis with topical preservative-free dexamethasone (DEX), diclofenac (DICLO), or their combination (DEX+DICLO). Our main outcome measure was an intraocular pressure (IOP) change of a minimum 4 mmHg following the withdrawal of anti-inflammatory prophylaxis 9 weeks after trabeculectomy. We found that the IOP decreased ≥ 4 mmHg in 18.6% of eyes after cessation of the topical steroid DEX (n = 3/22) and DEX+DICLO (n = 5/21), whereas a decrease in IOP was not observed in the DICLO group. In conclusion, IOP decreased in nearly 1/5 of patients after cessation of topical steroidal anti-inflammatory prophylaxis after trabeculectomy. This points toward a steroid-induced increase in IOP even after trabeculectomy. Thus, increased postoperative IOP may be related to steroid use, and the success or failure of a trabeculectomy cannot be fully evaluated before anti-inflammatory prophylaxis with steroids is stopped or changed to non-steroidal eye drops.

Advancements in Postoperative Care after Cataract Surgery

Cataract surgery is one of the most frequently performed surgical procedures in many countries [...].

Comparison of Efficacy between Non-Steroidal Anti-Inflammatory Drugs and Anti-Vascular Endothelial Growth Factor in Preventing Macular Edema after Cataract Surgery in Diabetic Patients

(1) Background: There is no consensus regarding the optimal strategy to prevent macular edema after cataract surgery in diabetic patients. The purpose of study is to compare the efficacy of topical nonsteroidal anti-inflammatory agents (NSAIDs) and intravitreal injections of anti-VEGFs for the prevention of macular edema after cataract surgery in diabetic patients without pre-existing macular edema. (2) Methods: A literature search of the MEDLINE, PUBMED, and EMBASE databases was conducted in July 2021. Studies involving either topical NSAIDs or intravitreal injections of anti-VEGF arms that reported either the occurrence of macular edema or changes in best corrected visual acuity (BCVA) were included. Weighted mean differences and risk ratios were calculated along with 95% confidence intervals. (3) Results: Intravitreal injection of anti-VEGFs provided short-term structural protection for one month in patients receiving cataract surgery, but the protective effect ceased to exist after three months. The structural protection of topical NSAIDs, however, can last for at least three months. Meanwhile, neither anti-VEGFs nor NSAIDs provided significant visual improvement. (4) Conclusions: Our study suggested that topical NSAIDs eye drops is an effective prevention strategy for macular edema after cataract surgery in diabetic patients.

Effect of cataract surgery on wet age-related macular degeneration activity

BACKGROUND

Wet age-related macular degeneration (AMD) and age-related cataract are often coexisting causes of visual impairment. Yet, the timing of cataract surgery in wet AMD patients is controversial.

METHODS

One hundred and eleven eyes of 111 patients with wet AMD underwent cataract surgery at Helsinki University Hospital in Finland during 2014-2018. Best-corrected visual acuity and central subfield macular thickness (CSMT) were analysed at the time of wet AMD diagnosis, at the last recording prior to cataract surgery and at the first recording and at 1 year after surgery. The cumulative number of antivascular endothelial growth factor (anti-VEGF) injections at surgery, systemic and topical medication and postoperative anti-VEGF burden were recorded.

RESULTS

Mean age was 78.9 ± 5.6 years at the time of surgery. Central subfield macular thickness (CSMT) significantly decreased (280.1 ± 75.0 µm preoperatively to 268.6 ± 67.6 µm at the first postoperative recording, p = 0.001, and to 265.9 ± 67.9 µm at 1 year, p = 0.003), visual acuity improved (0.70 ± 0.46 logMAR units preoperatively to 0.39 ± 0.40 at the first postoperative recording, and to 0.33 ± 0.34 at 1 year, p < 0.001 for both) and anti-VEGF treatment intervals lengthened despite the surgery (6.53 ± 2.08 weeks prior to surgery to 7.03 ± 2.23 weeks at 1 year, p = 0.246, and to 7.05 ± 2.57 weeks at the last documented visit, p = 0.035). A CSMT increase of over 30% from the preoperative values was seen in only one case (1 out of 111 eyes, 0.9%). Macular status at surgery, wet AMD subtype, comorbidity of type II diabetes, systemic drugs and topical anti-inflammatory medication were not associated with macular changes nor with treatment intervals after surgery. The cumulative number of anti-VEGF injections correlated neither with CSMT change postoperatively (r = -0.051, p = 0.619) nor with CSMT change at 1 year (r = 0.091, p = 0.426).

CONCLUSION

Satisfactory visual outcomes and controlled disease activity were seen in patients with wet AMD undergoing cataract surgery. We found no evidence to support delaying surgery in patients who require it.

Corneal Thickness and Anterior Chamber Flare After Cataract Surgery: A Randomized Controlled Trial Comparing Five Regimens for Anti-Inflammatory Prophylaxis

Purpose

To investigate the relationship between early post-operative anterior chamber inflammation (aqueous flare) and central corneal thickness (CCT) after cataract surgery and to evaluate the effect of anti-inflammatory prophylaxis on CCT.

Setting

Department of Ophthalmology, Rigshospitalet-Glostrup, University Hospital Copenhagen, Denmark.

Design

Post-hoc analysis of a prospective randomized controlled trial.

Patients and Methods

A total of 470 participants who underwent standard cataract surgery were randomly allocated to prophylactic treatment with nonsteroidal anti-inflammatory drug (NSAID, groups C and D) or a combination of NSAID and steroid eye drops (groups A and B), commenced either pre-operatively (A and C) or post-operatively on the day of surgery (B and D), or "drop-less surgery" (peri-operative subtenon depot of dexamethasone, group E). Aqueous flare was measured before and three days after surgery. CCT was measured before surgery, three days, three weeks, and three months after surgery. Data were analyzed according to the intention-to-treat method.

Results

Doubling of aqueous flare increased mean CCT by 15.6 microns (95% CI 9.8; 21.3, P<0.001) three days after surgery. Mean CCT increased from 549 microns (95% CI 545; 552) at baseline to 594 microns (95% CI 585; 602) three days after surgery and returned to 551 microns (95% CI 545; 557) three months after surgery. Mean CCT was thinner in group C compared to group A three days after surgery. No difference was found for any other groups or time points.

Conclusion

Increased anterior chamber inflammation was associated with significant corneal thickening three days after cataract surgery. Choice of anti-inflammatory regimen seemed to be of no or minimal importance on CCT when the effect of inflammation was accounted for. Corneal thickening is possibly mediated by underlying deterioration of the blood-aqueous barrier and corneal endothelium pump function caused by a post-operative inflammatory response.

Relationship Between Prolonged Intraocular Inflammation and Macular Edema After Cataract Surgery

Purpose

To assess whether aqueous flare is related to an increased risk of pseudophakic cystoid macular edema (PCME) following uneventful cataract surgery in nondiabetic and diabetic patients.

Methods

A post hoc analysis of five consecutive randomized clinical trials in the Department of Ophthalmology, Kymenlaakso Central Hospital, Finland. Aqueous flare levels were recorded in 448 eyes of 448 patients before surgery, and after the course of topical anti-inflammatory treatment 28 days and three months after cataract surgery.

Results

Aqueous flare increase of <50%, ≥50%, ≥100%, and ≥200% associated in central subfield macular thickness (CSMT) increase across the groups at 28 days and three months after surgery. Increase of aqueous flare ≥100% compared to those with <100% was associated with increased CSMT (P = 0.022 at 28 days, and P = 0.027 at three months). At three months, macular thickening (at least 10% CSMT increase) was observed in 12.7% compared to 4.6% of eyes when using a cutoff value of 100% increase in aqueous flare (P = 0.033). Although diabetic patients presented higher aqueous flare levels at baseline compared to nondiabetic patients (12.9 ± 11.8 vs. 9.8 ± 8.2 photon units/ms P < 0.001), the postoperative levels illustrated a similar profile in aqueous flare increase between the two groups.

Conclusions

At 28 days, aqueous flare increase was associated with macular thickening. A 100% cutoff value could potentially be used when studying anti-inflammatory efficacy of different treatment protocols. Flare values exceeding this cutoff value could be considered as an indication for extending anti-inflammatory therapy.

Translational Relevance

A 100% increase in aqueous flare at 28 days after cataract surgery from baseline predicted macular thickening up to three months postoperatively. Identifying a correlation between increased aqueous flare levels and pseudophakic cystoid macular edema may allow recognition of the most vulnerable patients, development of prophylactic treatment strategies and reduction of the number and severity of postoperative complications.

Anti-inflammatory treatment after cataract surgery in Sweden: changes in prescribing patterns from 2010 to 2017

Aims

To investigate changes in the prescribing patterns of postoperative eye drops following cataract surgery in Sweden from 2010 to 2017.

Methods

Data from cataract procedures registered in the National Cataract Register during the month of March from 2010 to 2017 were record linked and sent to the Swedish Prescribed Drug Register, which allowed us to determine which eye drops the patients had obtained from 3 months presurgery to 2 weeks post surgery.

Results

During the 8-year study period, 54 889 surgeries were registered. Combination treatment with steroid and non-steroidal anti-inflammatory drug (NSAID) eye drops increased from 12% in 2010 to 60% in 2017 (p<0.001) while monotherapy with steroids decreased from 71% in 2010 to 26% in 2017 (p<0.001). Monotherapy with NSAIDs after surgery was fairly stable, at 17% in 2010 and 13% in 2017 (p<0.001). Combination treatment was more frequent in patients with diabetic retinopathy (p<0.001) or age-related macular degeneration (p<0.001), while monotherapy with steroids was more frequent in patients with glaucoma (p<0.001). The proportion of monotherapy or combination therapy varied widely between ophthalmic clinics. The prescription of antibiotic eye drops after surgery also varied greatly between clinics, from 0% to 63%, with a national average of 4.9%.

Conclusion

There is a change in the prescription pattern of anti-inflammatory eye drops after cataract surgery in Sweden, with less monotherapy and an increasing proportion of patients receiving a combination of steroid and NSAID eye drops.

Effect of anti-inflammatory regimen on early postoperative inflammation after cataract surgery

PURPOSE

To investigate whether a combination of topical nonsteroidal anti-inflammatory drugs (NSAIDs) and steroids were superior in controlling early postoperative inflammation after cataract surgery compared with topical NSAIDs alone and with dropless surgery where a sub-Tenon depot of steroid was placed during surgery.

SETTING

Department of Ophthalmology, Rigshospitalet-Glostrup, Denmark.

DESIGN

Prospective randomized controlled trial with masked statistical analyses.

METHODS

Patients undergoing phacoemulsification for age-related cataract were randomized to 1 of 5 regimens: ketorolac and prednisolone eyedrops combined (Pred+NSAID-Pre [control group] and Pred+NSAID-Post group) vs ketorolac monotherapy (NSAID-Pre and NSAID-Post groups) vs sub-Tenon depot of dexamethasone (dropless group). Drops were used until 3 weeks postoperatively, starting 3 days preoperatively in the Pre groups and on the day of surgery in the Post groups. Aqueous flare was measured at baseline and 3 days postoperatively.

RESULTS

Four hundred fifty-six participants, with a mean age of 72.1 (SD 7.0) years and 283 (62%) women, were included. Flare increased significantly more in the dropless group compared with the control group (Pred+NSAID-Pre), but none of the other groups differed significantly from the control group. Intraocular pressure decreased in all groups but significantly less in groups receiving prednisolone eyedrops (Pred+NSAID-Pre and Pred+NSAID-Post groups) compared with NSAID monotherapy and dropless groups. No differences in postoperative visual acuity were found compared with the control group.

CONCLUSIONS

No differences were found between groups randomized to NSAID monotherapy or combination of NSAID and steroid in controlling early inflammation after cataract surgery, but sub-Tenon depot of dexamethasone was less efficient. Initiating prophylactic eyedrops prior to surgery did not influence early postoperative anterior chamber inflammation.

Topical preservative-free ophthalmic treatments: an unmet clinical need

Introduction: The main role of preservatives in eyedrops is to ensure sterility and microbiological integrity of the drug, and to facilitate the penetration of active compounds into the eye. However, several studies documented significant toxic effects induced by preservatives, especially on the ocular surface. Consequently, most of the ophthalmic medications became progressively available in preservative-free (PF) formulations.Areas covered: We analyzed pre-clinical and clinical studies on PF eyedrops with particular attention to common chronic diseases such as dry eye and glaucoma. We discussed about the pros and cons of using PF eyedrops, in terms of efficacy, safety, and social-economic aspects.Expert opinion: There are still unresolved issues that make hard for PF medications to definitively conquer the drug market. Despite robust pre-clinical evidences of less toxicity, the low number of randomized clinical trials does not permit to state that PF eyedrops have, in clinical practice, a similar efficacy or a higher safety compared to preserved forms. These aspects limit their use to chronic diseases requiring long-term therapies with multiple daily instillations, especially in the presence of concomitant ophthalmic diseases that expose to a risk of ocular surface worsening.

Clinical Course of Pseudophakic Cystoid Macular Edema Treated with Nepafenac

Background: To evaluate the clinical course of pseudophakic cystoid macular edema (PCME) treated with topical non-steroidal anti-inflammatory drugs (NSAIDs). Methods: An analysis of the clinical course of PCME consisting of 536 eyes of 536 patients from five consecutive randomized clinical trials aimed at the optimization of anti-inflammatory medication in patients undergoing routine cataract surgery. PCME was classified as (i) grade 0a; no macular thickening, (ii) grade 0b; macular thickening (central subfield macular thickness (CSMT) increase of at least 10%) without signs of macular edema, (iii) grade I; subclinical PCME, (iv) grade II; acute PCME, (v) grade III; long-standing PCME. Eyes with PCME classification from grade I onwards were treated with nepafenac 1 mg/mL t.i.d. for two months. Results: CSMT increase of at least 10% at any postoperative timepoint with cystoid changes—a criterion for PCME—was found in 19 of 536 eyes (total incidence 3.5%). Of these 19 eyes, 13 eyes (total incidence 2.4%) had clinically significant PCME. PCME was considered clinically significant when both of the following visual acuity criteria were fulfilled. At any timepoint after the cataract surgery both the corrected distance visual acuity (CDVA) gain was less than 0.4 decimals from that of preoperative CDVA, and the absolute CDVA level remained below 0.8 decimals. Only one of the 19 eyes with criteria for PCME (total incidence 0.2%, incidence of PCME eyes 5.3%) showed no macular edema resolution within 2 months after topical nepafenac administration. Conclusions: PCME in most cases is self-limiting using topical nepafenac without any further need for intravitreal treatment.

Incidence of pseudophakic cystoid macular edema in eyes with and without pupil expansion device

PURPOSE

Novel pupil expansion devices are widely recognized for their intraoperative feasibility in safe small pupil cataract surgeries. To assess whether the use of pupil expansion devices affects recovery from cataract surgery.

METHODS

A post hoc analysis of five consecutive prospective randomized clinical trials. 536 eyes of 536 patients undergoing routine cataract surgery were analysed according to the use of pupil expansion device. Thirty-four eyes were operated with pupil expansion device and 502 eyes without. Clinical outcome parameters were recorded at 28 days and 3 months.

RESULTS

Patient age and gender distribution, and baseline clinical outcome parameters were comparable between study groups. Pseudoexfoliation syndrome, glaucoma and medication for benign prostatic hyperplasia were more frequently present; phacoemulsification energy was higher and operation time longer in eyes with pupil expansion device. At 28 days, aqueous flare increased by 12.0 ± 25.1 pu/mseconds and mean central subfield macular thickness by 16.2 ± 24.4 μm in eyes with pupil expansion device, when compared to 4.6 ± 14.8 pu/mseconds (p = 0.015) and 7.0 ± 33.9 μm (p = 0.064) in eyes without the device. At 3-month follow-up, clinically significant pseudophakic cystoid macular edema (PCME) was reported in 12% of eyes with pupil expansion device and in 2% of eyes without (p = 0.006). After adjusting for the presence of confounding factors, hazard for clinically significant PCME was greater in eyes with pupil expansion device than in those without (HR 5.41, 95% CI 1.35-21.71, p = 0.017).

CONCLUSIONS

The use of pupil expansion device may predispose eyes to increased risk of clinically significant PCME. Effective anti-inflammatory treatment and follow-up are warranted in eyes with pupil expansion device.

Novel Triamcinolone Acetonide-Loaded Liposomal Topical Formulation Improves Contrast Sensitivity Outcome After Femtosecond Laser-Assisted Cataract Surgery

Purpose: To assess visual results, macular modifications, and the incidence of clinically significant macular edema (CSME) in patients using a topical triamcinolone acetonide-loaded liposomal formulation (TA-LF) after femtosecond laser-assisted cataract surgery (FLACS). Methods: Fifty-six eyes after FLACS were selected. Twenty-eight eyes in the combined therapy group (P + N) were treated with prednisolone 1% and nepafenac 0.1% for 21 days postoperatively, whereas 28 eyes in the TA-LF group received a liposomal formulation containing 2 mg/mL of TA (0.2%) for the same period of time. Follow-up visits at 1 day, 6 weeks, and 12 weeks after surgery consisted of visual acuity, contrast sensitivity (CS), central foveal thickness (CFT), total macular volume (TMV) measurements, and the detection of CSME. Results: CS improved in the TA-LF group (basal value: 1.087 ± 0.339 vs. 1.276 ± 0.147 at week 12, P = 0.0346), whereas in the P + N group, CS was not different from the baseline (basal value: 1.130 ± 0.331 vs. 1.274 ± 0.133 at week 12, P = 0.1276). There were similar increases in postoperative CFT and TMV in both groups. CFT and TMV significantly correlate with CS only in the TA-LF group. The r² for CFT and CS was 0.1963 (P = 0.0206), whereas the r² for TMV and CS was 0.3615 (P = 0.0007) at 12 weeks. No difference was observed in the incidence of CSME between the groups. Conclusion: TA-LF is associated with better CS outcomes compared to combined therapy after FLACS.

Systemic use of calcium channel blockers associated with less increase in central retinal thickness after uncomplicated cataract surgery

PURPOSE

To examine the role of systemic medication on the risk of pseudophakic cystoid macular edema (PCME) following uneventful cataract surgery.

METHODS

A total of 269 eyes undergoing routine cataract surgery. Spectral-domain optical coherence tomography imaging was conducted before surgery and at 28 days. Information about medication of the participants was gathered from The National Archive of Health Information (Kanta), an electronic pharmaceutical database.

RESULTS

Systemic medication with angiotensin converting enzyme inhibitor/angiotensin II receptor antagonists (p < 0.001), beta-blockers (β-blockers) (p = 0.002), calcium channel blockers (CCBs) (p < 0.001), nitrates (p =0.021) and lipophilic HMG-CoA reductase inhibitors (statins) (p < 0.001) were more frequently prescribed to diabetic compared with nondiabetic patients. In eyes with steroid monotherapy (N = 135), concomitant systemic medication with β-blockers (12.9 ± 24.0 μm versus 28.6 ± 59.5 μm, p = 0.045), CCBs (12.0 ± 22.1 μm versus 26.3 ± 55.6 μm, p = 0.041) and statins (12.9 ± 22.8 μm versus 30.0 ± 61.9 μm, p = 0.038) attenuated a change in central retinal thickness (CRT) when compared to patients not receiving medication. In multivariable analysis, the use of CCBs remained as an independent protective factor against macular swelling at 28 days (-0.23; 95% CI [-0.43 to -0.04]; p = 0.021), when all systemic medications showing statistical significance were included (i.e. β-blockers, CCBs and statins) together with diabetes status. In eyes with nonsteroidal anti-inflammatory drug (NSAID) monotherapy (N = 67) and steroid and NSAID combination therapy (N = 67), CRT increase was moderate both with and without use of systemic medications.

CONCLUSION

Systemic vasoactive medication may be protective against CRT change induced by cataract surgery in eyes at risk of PCME such as those with postoperative steroid monotherapy.

Diabetes Alone Does Not Impair Recovery From Uneventful Cataract Surgery

PURPOSE

To study the outcomes of uneventful cataract surgery in diabetic patients without retinal complications.

DESIGN

A post hoc treatment analysis using data from 2 double-masked randomized clinical trials.

METHODS

Setting: Conducted at Kymenlaakso Central Hospital, Kotka, Finland.

PROCEDURE

A total of 276 eyes of 266 patients undergoing routine cataract surgery were included in the study. Patients with type I or II diabetes (n = 56 eyes) were compared to nondiabetic patients (n = 220 eyes). Clinical evaluation was conducted by the operating physician, and outcome measures taken before surgery and day 28 were recorded by a research technician.

RESULTS

Patient age, sex distribution, and all baseline ophthalmic and surgical parameters were comparable for the nondiabetic and diabetic patient groups. Increase in aqueous flare 6.3 ± 16.4 photon units (pu)/ms vs 3.7 ± 8.9 pu/ms (mean ± standard deviation; P = .282), central retinal thickness (CRT) 12.0 ± 38.2 μm vs 5.9 ± 15.8 μm (P = .256), corrected distance visual acuity 0.57 ± 0.31 decimals vs 0.53 ± 0.35 decimals (P = .259), and patient satisfaction 9.3 ± 0.9 vs 9.2 ± 1.1 (P = .644) were comparable for nondiabetic and diabetic patients. In eyes with steroid monotherapy (n = 64), CRT increased 38.1 ± 72.8 μm in nondiabetic patients compared to 7.8 ± 6.6 μm in diabetic ones (P = .010). In eyes with nonsteroidal anti-inflammatory drug (NSAID) monotherapy (n = 157), CRT increased 5.7 ± 18.4 μm in nondiabetic patients compared to 6.2 ± 20.5 μm in diabetic ones (P = .897). Among eyes with steroid and NSAID combination therapy (n = 55), CRT increased 3.6 ± 4.1 μm in nondiabetic patients compared to 2.9 ± 3.2 μm in diabetic ones (P = .606). At 28 days postsurgery, pseudophakic cystoid macular edema (PCME) was reported in 8 eyes, of which 7 were in nondiabetic patients (P = 1.000).

CONCLUSIONS

Diabetic patients showed less change in CRT when compared to controls in steroid monotherapy. Other outcome measurements shows no statistical differences.

Postoperative management in cataract surgery: nepafenac and preservative-free diclofenac compared

PURPOSE

Current cataract surgery guidelines recommend routine use of topical nonsteroidal anti-inflammatory drugs (NSAIDs) in preventing pseudophakic cystoid macular oedema (PCME). Here, we compare the clinical efficacy and tolerability of two potent NSAIDs, nepafenac and preservative-free diclofenac following cataract surgery.

METHODS

Randomized, double-blind, prospective single-centre study. Ninety-six eyes of 95 patients undergoing routine cataract surgery were randomized 1:1 either to nepafenac (Nevanac, 1 mg/ml) or diclofenac (Dicloabak, 1 mg/ml) for 3 weeks. Seventy-three patients accounting for 73 eyes completed the entire follow-up. Aqueous flare and central retinal thickness (CRT) analysis were conducted preoperatively and at control visits 28 days and 3 months after surgery. A structured home questionnaire and interview were used to record any adverse effects of the topical medications, subjective visual recovery and the dispenser's ease of use.

RESULTS

No differences were observed between the groups for aqueous flare, CRT, speed of recovery or visual acuity gain. Seven patients (16%) on nepafenac and 20 patients (48%) on preservative-free diclofenac reported symptoms related to topical use of NSAID medications (p = 0.001).

CONCLUSION

No differences in clinical efficacy were found between potent NSAIDs, while tolerability might be an issue.

Macular edema after cataract surgery in eyes with and without pseudoexfoliation syndrome

BACKGROUND

The purpose of the study was to identify macular edema after cataract surgery in eyes with and without pseudoexfoliation syndrome. The study was a post-hoc analysis of a randomized, double-blind, prospective single-center study. Patients were enrolled between January 2016 and October 2016 as per the national guidelines for the management of cataract in the Department of Ophthalmology, Kymenlaakso Central Hospital, Kotka, Finland.

METHODS

One hundred and fifty-six eyes of 149 patients undergoing routine cataract surgery. Postoperatively anti-inflammatory medication was either dexamethasone (N = 78) or diclofenac (N = 78). Spectral domain optical coherence tomography imaging and laser flare meter measurement of the anterior chamber were conducted before surgery and at the control visit 28 days postoperatively.

RESULTS

Baseline variables were comparable between eyes with pseudoexfoliation syndrome (N = 32) and those without (N = 124), except for intraocular pressure (P = 0.002) and glaucoma medication (P < 0.001). In patients having pseudoexfoliation syndrome, central retinal thickness increase (mean ± standard error of the mean) was 63.3 ± 35.5 μm for dexamethasone and 17.6 ± 5.8 μm for diclofenac, compared to 28.9 ± 8.0 μm (P = NS) and 6.9 ± 1.3 μm (P = 0.014) in eyes without pseudoexfoliation syndrome, respectively. Aqueous flare at 28 days was 25.8 ± 5.4 pu/ms for patients with pseudoexfoliation syndrome and 18.3 ± 1.8 pu/ms for those without (P = 0.030). Best corrected visual acuity gain and best corrected visual acuity at 28 days were less in patients having pseudoexfoliation syndrome compared to those without (0.39 ± 0.07 vs 0.59 ± 0.03 decimals, P = 0.007; and 0.77 ± 0.06 vs 0.92 ± 0.03 decimals, P = 0.008, respectively).

CONCLUSION

Eyes with pseudoexfoliation syndrome may be predisposed to an increased aqueous flare and macular edema after cataract surgery. This study outlines the need to determine the optimal anti-inflammatory medication after cataract surgery in patients with pseudoexfoliation syndrome.