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

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.

Topical NSAIDs impact on macular oedema and visual outcome after phacoemulsification: systematic review of RCTs with network meta-analysis

The aim of this Network Meta-analysis was to compare the efficacy of the different topical Nonsteroidal anti-inflammatory drugs (NSAIDs) when added or not to topical steroids in preventing the thickening of the macula and their impact on visual acuity and intraocular pressure after phacoemulsification. Five electronic databases were searched, including PubMed, Embase, Scopus, Cochrane Library, and ClinicalTrials.gov. Our primary outcome was one-month post-surgery visual outcome. We also considered change in Foveal thickness (FT) and Intraocular pressure (IOP) at one-month post-surgery. We summarized our analyses by calculating the mean differences (MD) with associated 95% confidence intervals (CI) using restricted maximum likelihood in random effects models for continuous outcomes. The methodological quality of the studies was assessed with Cochrane Collaboration's tool. The network meta-analysis was conducted using frequentist approach considering Nepafenac 0.1% as a reference medication. Eleven Randomized controlled trials (RCTs) including 2175 subjects were selected for quantitative analysis. At one-month post-surgery, Bromfenac had statistically significant better visual acuity compared to Nepafenac 0.1% (p < 0.001), regarding FT, Nepafenac 0.3% had the least increase in FT compared to Nepafenac 0.1% (p = 0.09), regarding IOP, Diclofenac had the lowest IOP. No significant results regarding FT and IOP. Interestingly Ketorolac had the worst results regarding BCVA and IOP, and came last but one for FT. Overall, our network meta-analysis demonstrated that Bromfenac was associated with a significant improvement in visual acuity compared to Nepafenac 0.1% at one-month following cataract surgery, while Nepafenac 0.3% was associated with the least increase in foveal thickness.

Uveitis in the Pediatric Population and Therapeutic Management: A Current Literature Review

Uveitis is an inflammatory disease that can lead to severe complications, including vision loss. The pediatric population is particularly at risk of developing complications, as uveitis in this age group often has idiopathic origins or is associated with systemic diseases that follow a severe course. This, coupled with unfavorable treatment outcomes, continues to be a challenge in pediatric ophthalmology. The cornerstone of uveitis treatment involves a therapeutic strategy that depends on the etiology, severity, and localization of the inflammation, as well as the patient's response to treatment and the presence of ocular complications. Patients who do not receive timely treatment face a significantly increased risk of experiencing a severe disease course. Understanding potential therapeutic options and their side effects is crucial in managing children with uveitis. Equally important is the continuous monitoring of the child's condition throughout the treatment process, due to the chronic and recurrent nature of uveitis in this demographic. The authors conducted a review of the current literature from 2018 to 2023 on the management and introduction of new therapeutic approaches for children with uveitis.

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.

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.

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.

Prophylaxis of macular edema after cataract surgery in diabetic patients, topical Nepafenac versus intravitreal Ranibizumab

PURPOSE

To compare effect of topical Nepafenac versus intravitreal Ranibizumab on macular thickness after cataract surgery in diabetic patients with no preoperative macular edema.

PATIENTS AND METHODS

A prospective randomized controlled study recruited diabetic patients with visually significant cataract and no diabetic macular edema (DME). Patient underwent uncomplicated phacoemulsification with IOL implantation and were randomly assigned to receive post-operative topical Nepafenac, intra-operative intravitreal Ranibizumab, or no prophylactic treatment. Changes in subfoveal and perifoveal macular thickness were assessed by SD-OCT.

RESULTS

The mean central macular thickness showed a significant increase in all study groups 1 week and 1 month postoperative when compared to baseline. At 3 months postoperative, there was a significant difference between Nepafenac and Control group (p = 0.017), Ranibizumab and Control groups (p = 0.009) with no significant difference between Nepafenac and Ranibizumab group (p = 0.545) regarding CMT. Comparable results could be detected as regarding peri-foveal macular thickness changes. Concerning BCVA, there was a significant difference between topical Nepafenac/control (p = 0.001) and intravitreal Ranibizumab/control (p = 0.004) at 1-week visit. No significant difference in BCVA was observed between Nepafenac and Ranibizumab group throughout the whole study period. In postoperative visits, cystoid macular edema occurred in three patients (7.9%) in Nepafenac group, one patient (2.7%) in Ranibizumab group, and seven patients (17.07%) in control group.

CONCLUSION

Both postoperative topical Nepafenac and intra-operative intra-vitreal Ranibizumab are effective adjunctive to phacoemulsification in diabetic patients for prophylaxis of macular edema.

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.

Cataract complications study: an analysis of adverse effects among 14,520 eyes in relation to surgical experience

Background

To evaluate the learning-curve in performing cataract surgery with respect to developments in technology and different teaching strategies by comparing the incidence of capsular bag-related complications to operator experience.

Methods

A review of the registry of 14,520 cataract surgeries carried out at the Ophthalmology Unit of Kymenlaakso Central Hospital, Kotka, Finland, from August 8, 2009 to July 31, 2017.

Results

We identified 144 cases with posterior capsule rupture and/or loss of capsular bag support (incidence 0.99% of all surgeries). The mean age of patients was 76.9±9.1 years and gender distribution ratio 29:71 male:female. Pseudoexfoliation syndrome (PXF; incidence 21%) and small pupil (incidence 14%) were over-represented in complication eyes, especially at the beginning of the study. Capsular bag-related complication rates were reported in 0.36% of surgeries for senior and 7.03% for resident surgeons at the beginning of the study, compared to 0.32% and 1.32%, respectively, at the end of the study. Best-corrected visual acuity at the final post-operative visit was 0.61±0.16 decimals at the beginning of the study, and 0.81±0.19 decimals at the end of the study. The mean number of post-operative visits was 4.3±2.7 and did not show trend over the study period.

Conclusions

Real-world evidence suggests PXF and small pupil as significant risk factors in cataract surgery. A gradual decline in the rate complications was noted with increasing surgical experience, also among residents over the follow-up period.

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.

Anti-inflammatory Medication of Cataract Surgery in Pseudoexfoliation Syndrome - NSAID Is Needed

BACKGROUND

To optimize the anti-inflammatory treatment of cataract surgery in pseudoexfoliation syndrome (PXF) eyes.

METHODS

A prospective randomized double-masked trial. Sixty eyes of 60 patients with PXF undergoing routine cataract surgery were randomized for potent topical postoperative anti-inflammatory medication either with prednisolone acetate (10mg/ml), nepafenac (1mg/ml) or their combination. Clinical outcome parameters were recorded at 28 days and 3 months. Recovery from surgery was recorded by a structured home questionnaire.

RESULTS

Patient age and gender distribution, and all baseline ophthalmic and surgical parameters were comparable between the study groups. At 28 days, change in central subfield macular thickness was +11.4 ± 11.9 µm in prednisolone acetate group compared to +1.7 ± 16.8 µm in nepafenac (P = .017), and -0.3 ± 8.7 µm in combination therapy (P = .010) groups. At 3 months, the values were +11.8 ± 18.1 µm, +1.8 ± 17.5 µm (P = .055), and -1.3 ± 6.4 µm (P = .055), respectively. Pseudophakic cystoid macular edema (PCME) was reported in two eyes, both with prednisolone acetate monotherapy. After surgery, conjunctival injection lasted 6.5 ± 5.0 days and irritation of the eye 9.5 ± 8.5 days in prednisolone acetate group compared with nepafenac (2.6 ± 2.2 days; P = .037 and 4.3 ± 5.2 days; P = NS, respectively) and combination therapy (3.3 ± 1.9 days; P = NS and 3.0 ± 4.0 days; P = .025, respectively).

CONCLUSIONS

Routine cataract surgery of PXF eyes with nonsteroidal anti-inflammatory drugs (NSAID) alone, or in combination with steroids resulted in faster recovery from surgery and avoidance of PCME compared to steroids alone.

ABBREVIATIONS

BAB: blood-aqueous barrier; CDVA: corrected distance visual acuity; CDE: cumulative dissipated energy; CSMT: central subfield macular thickness; HRQoL: Health-related quality of life; IOP: intraocular pressure; logMAR: log of the minimum angle of resolution; NSAID: nonsteroidal anti-inflammatory drug; PCME: pseudophakic cystoid macular edema; PXF: pseudoexfoliation syndrome; OCT: optical coherence tomography; t.i.d.: three times a day; VA: visual acuity.

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.

Preoperative anti-inflammatory treatment of diabetic patients does not improve recovery from cataract surgery when postoperatively treated with a combination of prednisolone acetate and nepafenac

PURPOSE

To examine preoperative anti-inflammatory treatment on recovery from cataract surgery in eyes of diabetic patients.

METHODS

A Prospective randomized clinical trial. One hundred and three eyes of 103 patients with diabetes undergoing routine cataract surgery were randomized (1:1) not to receive any preoperative anti-inflammatory medication or to receive preoperative topical anti-inflammatory medication with a combination of prednisolone acetate (10 mg/ml) and nepafenac (1 mg/ml). All eyes received postoperative anti-inflammatory combination therapy for 3 weeks. Recovery from surgery was recorded by a structured home questionnaire. Clinical outcome parameters were recorded at 28 days and 3 months.

RESULTS

Patient age and gender distribution, and all baseline ophthalmic and systemic parameters were comparable between the study groups. After surgery, conjunctival injection lasted 2.4 ± 1.7 days (mean ± SD) and irritation of the eye 3.3 ± 3.9 days in eyes without preoperative treatment, when compared to 1.6 ± 1.6 days (p = 0.067) and 2.4 ± 4.0 days (p = 0.431), respectively, in eyes with preoperative treatment. At 28 days, central subfield macular thickness (CSMT) increased 2.2 ± 20.2 μm in eyes without preoperative treatment, when compared 0.1 ± 25.2 μm (p = 0.670) in eyes with preoperative treatment. At 3 months, the respective CSMT change from baseline was -1.5 ± 26.9 μm and -3.4 ± 26.2 μm (p = 0.762). None of the eyes were reported with pseudophakic cystoid macular oedema (PCME) in either group.

CONCLUSION

Lack of preoperative anti-inflammatory treatment does not impair recovery from surgery or predispose diabetic patients to increased risk of PCME in eyes postoperatively treated with combination therapy of prednisolone acetate and nepafenac.

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.