Inhibition of surgically induced miosis and prevention of postoperative macular edema with nepafenac

Nepafenac role in macular swelling prevention and in visual outcome after cataract surgery - a systematic review and meta-analysis

PURPOSE

To compare Nepafenac effect on foveal thickness (FT), total macular volume (TMV), and BCVA after cataract surgery when added to the common regimen of topical steroids perioperatively.

METHODS

PubMed, Scopus, EMBASE, the Cochrane Library, and ClinicalTrials.gov were searched systematically on April 28, 2022, for RCTs. Our primary outcome was the change in FT at final follow-up visits. We also considered FT at different follow-up durations, TMV, and visual outcome. 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 individual trials were evaluated for quality utilizing the Cochrane Collaboration's risk of bias assessment tool.

RESULTS

Twenty-four RCTs totaling 4716 eyes were eligible. A significant difference was found between Nepafenac group and control group in the change in FT at final follow-up visit (MD, -11.622; 95% Cl [-17.475, -5.769]), at one week follow-up visit (MD, -6.409; 95% Cl [-13.148, 0.330]), at one month follow-up visit (MD, -9.090; 95% Cl [-13.260, -4.919]), at two months (MD, -5.769; 95% Cl (-22.477, -10.939]), and at three-month follow-up visit (MD, -12.913; 95% Cl [-22.254, -3.572]). However, there was no significant difference between the two groups regarding change in TMV at final follow-up visit. Nevertheless, a significant difference was found between the two groups regarding post-operative BCVA only at three-month follow-up visit.

CONCLUSION

Topical Nepafenac in addition to topical steroid is superior to the common regimen of topical steroid alone perioperatively in the prevention of macular swelling.

Outcomes of retropupillary iris claw lens implantation in patients with intraocular lens dislocation and low (less than 1000 cells/mm2) corneal endothelial cell density

BACKGROUND

Posterior chamber intraocular lens (IOL) dislocation is a common complication of cataract surgery. Dislocated IOLs often require surgical intervention due to the potentially severe risks of leaving this condition untreated. If a patient with extremely low corneal endothelial cell density (ECD) presents with IOL dislocation, the surgeon faces a crucial dilemma of choosing the most optimal surgical treatment option. We sought to investigate the efficacy and safety of retropupillary iris claw intraocular lens (R-IOL) implantation in patients with IOL dislocation and extremely low (< 1000 cells/mm2) ECD.

METHODS

We retrospectively reviewed the medical records of nine patients (all men) whose pre-operative ECD was < 1000 cells/mm2 and who underwent R-IOL implantation due to intraocular subluxation or total dislocation into the vitreous cavity between 2014 and 2020. We evaluated corneal endothelial function and visual outcomes after surgery.

RESULTS

Nine patients were included in this study. The mean age at diagnosis was 64.89 ± 7.15 years (range 57-76 years), and the follow-up duration was 37.93 ± 23.72 months (range 18.07-89.07 months). No patients developed bullous keratopathy during follow-up. Compared to the initial ECD, corneal thickness (CT), coefficient variation of cell area (CV) and percentage of hexagonal cells (HEX), there was no statistically significant decrease in the ECD, CV, and HEX at last follow-up (P = 0.944, 0.778, 0.445, 0.443). There was significant improvement in the mean uncorrected distance visual acuity (UDVA) at the last follow-up (average 0.13 logMAR, 20/27 Snellen) compared to the pre-operative mean UDVA (average 1.09 logMAR, 20/250 Snellen) (P < 0.01).

CONCLUSIONS

R-IOL implantation did not result in a statistically significant decline in corneal endothelial function in patients with preoperatively low ECD, and it significantly improved the mean UDVA postoperatively. R-IOL implantation appears to be a safe and effective treatment modality for intraocular lens dislocation in patients with low ECD (< 1000 cells/mm²); however, long-term follow-up studies are warranted to corroborate these findings.

Comparison of the efficacy and safety of non-steroidal anti-inflammatory drugs and corticosteroid drugs for prevention of cystoid macular edema after cataract surgery

INTRODUCTION

To compare the efficacy and safety of non-steroidal anti-inflammatory drugs (NSAID), corticosteroid (CS), and a combination of both drugs to prevent cystoid macular edema (CME) after cataract surgery.

METHODS

We searched Pubmed, Cochrane Library, and Embase electronic databases to assess the relevant randomized controlled trials (RCTs) up to 28 April 2021. Network meta-analysis was registered on PROSPERO (CRD42020182520).

RESULTS

Twenty-four RCTs were included in this review. The NSAID and combination of both drugs were significantly reduced the risk of developing CME than CS alone in non-diabetics and mix populations. In the ranking profiles, the combination therapy showed a significant advantage over the single drugs and was less likely to develop CME. Diclofenac was the most likely to reduce the odds of developing CME compared with bromfenac and nepafenac. Dexamethasone was the most likely to reduce the odds of developing CME compared with betamethasone and fluorometholone.

CONCLUSION

NSAID combination with CS has significantly reduced the risk of developing CME postoperatively than the single drug. Diclofenac was superior to bromfenac and nepafenac in preventing CME. Dexamethasone was superior to betamethasone and fluorometholone in preventing CME.

Nepafenac in cataract surgery

The role of topical non-steroidal anti-inflammatory drugs (NSAIDs) in routine cataract surgery has been established since decades. Topical NSAIDs have been shown to reduce postoperative ocular inflammation and pain, preserve intraoperative mydriasis, and reduce the risk of postoperative cystoid macular oedema, whilst carrying a very low side-effect profile. Nepafenac is one of the currently available topical NSAIDs. The studies have shown that is has a high ocular penetration, allowing for potentially better results than other NSAIDs. This review gathers the current literature on the role of nepafenac in cataract surgery aiming to help surgeons maximise the benefits of its use to achieve improved surgical outcomes.

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.

Methods for achieving adequate pupil size in cataract surgery

PURPOSE OF REVIEW

Cataract surgery is the most common surgical procedure performed worldwide. Small pupils have been an eternal challenge for cataract surgeons; insufficient pupil dilation is associated with increased complication rates, including capsule rupture, vitreous loss, iris trauma or postoperative inflammation. The aim of the current review is to present the methods for pupil dilation and the risk factors for a small pupil in a cataract patient.

RECENT FINDINGS

Risk factors for intraoperative small pupil include diabetes, intraoperative floppy iris syndrome, pseudoexfoliation syndrome, receiving glaucoma medications, having undergone previous ocular surgery and iris sphincter sclerosis from aging. There is a wide range of options to manage the small pupil, including pharmacological treatment, mechanical stretching, dilation with iris hooks or pupil expanders. We recommend a stepwise approach for intraoperative pupil dilation, from pharmacological mydriasis to pupil expanders.

SUMMARY

The current article discusses risk factors for a small pupil and the methods for pupil dilation in a cataract patient. Every cataract surgeon needs to be ready to cope with a small pupil, both manifesting preoperatively and intraoperatively.

Safety & efficacy of single subconjunctival triamcinolone 5 mg depot vs topical loteprednol post cataract surgery: less drop cataract surgery

AIM

To do a randomized prospective interventional study for comparing the effects of a single subconjunctival triamcinolone acetonide (SCTA) injection to tapering topical loteprednol in patients undergoing phacoemulsification surgery under topical anesthesia.

METHODS

A total of 400 patients were randomized into 2 groups; Group A (200 patients) received 5 mg SCTA at the end of surgery and topical ketorolac tromethamine (0.5%) with ofloxacin (0.3%) combination for 3wk. Group B (200 patients) received tapering topical loteprednol etabonate (0.5%) along with ofloxacin (0.3%) and ketorolac tromethamine (0.5%) for 3wk. Outcomes evaluated were intraocular pressure (IOP), anterior chamber cells/flare and macular oedema postoperatively at 1, 6 and 12wk.

RESULTS

Baseline parameters were almost similar in both the groups. No statistical difference was seen between the preoperative and postoperative IOP values for Group A (P=0.82) and Group B (P=0.61) and postoperative IOP values in between both groups (P=0.14) at 1wk. Incidence of cells/flare postoperative was statistically not significant (P=0.82) in both groups at all follow up visits. Postoperative macular oedema was not observed at any follow up visit.

CONCLUSION

SCTA appears to be an effective alternative to prolong postoperative topical steroid use.

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.

Cataract surgery in small pupils

This paper presents the review of historical aspects and the current state-of-the-art in various pupil dilatation methods to be used in cataract surgery. The surgical algorithm in managing small pupil cases should include topical and intraocular mydriatics, appropriately selected viscosurgical device and mechanical dilatation with instruments, iris hooks, and/or pupil expanders.

Recent advances in small pupil cataract surgery

PURPOSE OF REVIEW

To highlight the existing and emerging cataract surgery trends in patients with insufficient mydriasis. Discuss the latest pharmacological approaches for pre and intraoperative pupil dilatation. Present the variety of newest pupil expansion devices; critically review their advantages and possible limitations to be considered by the surgeon.

RECENT FINDINGS

The intracameral use of various mydriatic combinations augmenting the preoperative mydriatic instillations is currently gaining popularity in cataract surgery. Two main options are available: bolus injection of pharmacological agent or its constant irrigation during the phacoemulsification procedure. The former is aimed to expand the pupil, whereas the latter is mostly preventing the pupil from constriction. Introduction of femtosecond-assisted cataract surgery, apart from some benefits was followed by a variety of adverse effects including prostaglandin release into the aqueous humor causing pupil constriction. Preoperative administration of nonsteroidal anti-inflammatory drugs at least 1 day prior to surgery significantly decreases the chance of pupil constriction after laser energy is applied to the eye. However, pupil expansion devices may be needed in up to 10% of cases. Following the success of the Malyugin ring (MicroSurgical Technology Inc., Redmond, Washington, USA) several manufacturers introduced pupil expansion devices of various designs. They are differing with materials, pupillary margin fixation mechanisms, and easiness of manipulations during implantation and removal.

SUMMARY

Combination of proper use of pre and intraoperative pharmacological pupil dilatation protocols combined with pupil expander rings allow for well tolerated and effective cataract surgery in the vast majority of patients with insufficient mydriasis.

Alternative Drug Delivery for Patients Undergoing Cataract Surgery as Demonstrated in a Canine Model

PURPOSE

(1) To determine ketorolac concentrations in selected ocular tissues following the intracameral administration of phenylephrine and ketorolac injection 1%/0.3% (OMIDRIA^®) delivered in irrigation solution during lens replacement surgery in beagle dogs. (2) To compare the ketorolac initial dose and resultant concentrations from the above study to those achieved in aqueous and vitreous by topical administration in patients undergoing cataract surgery or vitrectomy, respectively.

METHODS

Lens replacement surgery with phacoemulsification was performed in 20 female beagle dogs. A fixed combination of phenylephrine and ketorolac injection 1%/0.3% was diluted 125-fold into the balanced salt solution and delivered intracamerally during the phacoemulsification procedure. Ketorolac concentration was determined by liquid chromatography/mass spectrometry.

RESULTS

Concentrations of ketorolac when administered by the intracameral route in the dosing solution in dogs were found to be considerably higher in both aqueous and vitreous compared to what is achieved with topical dosing in patients.

CONCLUSIONS

Adequate therapeutic concentrations of ketorolac in aqueous and vitreous humor were achieved even at 10 h postdose. Critical concentrations in the aqueous that envelopes the iris/ciliary body, which are sites of prostaglandin E₂ synthesis, and the vitreous are not achieved by topical dosing in clinical studies after the surgery, but are by direct intracameral dosing as determined in this study. Based on these studies and clinical data, phenylephrine and ketorolac injection 1%/0.3% delivered during surgery as an irrigation solution may preclude the need for topically administered pre- and postoperative NSAIDs.

Intracameral Use of Nepafenac: Safety and Efficacy Study

PURPOSE

To test the intracameral safety of nepafenac and its efficacy in inhibiting prostaglandin synthesis during phacoemulsification surgery.

METHODS

The safety evaluation was conducted in normal eyes of rabbits, 0.1ml of 0.3% and 1% nepafenac was injected intracamerally. Extensive studies to detect adverse response ranged from a gross examination of eyes under slit lamp biomicroscope, fluorescein dye test, Schirmer tear test, test for corneal sensitivity, intraocular pressure measurement (IOP), specular microscopy, electroretinography(ERG), and histopathological examination of intraocular tissues. Efficacy of nepafenac was studied by intracameral injection of 0.1%, 0.3% nepafenac, nepafenac 0.3%+1% lignocaine, and 1% lignocaine alone, before phacoemulsification surgery and intraoperative mydriasis along with PGE2(ProstaglandinE2) secretion were recorded.

RESULTS

Single 0.1ml of 0.3% or 1% nepafenac did not significantly (p > 0.05) alter physiological parameters and histology of cornea, iris, and retina. Nepafenac 0.3% effectively inhibited PGE2 secretion. No significant (p > 0.05) prevention of miosis was recorded with 0.1% or 0.3% nepafenac. However, a combination of 0.3% nepafenac + 1% lignocaine and 1% lignocaine alone significantly (p < 0.05) arrested miosis during the intraoperative period.

CONCLUSION

An intracameral concentration of up to 1% nepafenac does not adversely affect the rabbit eye. Nepafenac fails to prevent miosis but inhibits prostaglandin release during phacoemulsification surgery.

Ophthalmic nepafenac use in the Netherlands and Denmark

Purpose

To describe nepafenac use in the Netherlands and Denmark with reference to its approved indications. For context, we also describe the use of ketorolac and diclofenac.

Methods

We identified users in the PHARMO Database Network (the Netherlands, 2008–2013) and the Danish national health registers (Denmark, 1994–2014). We described prevalence of cataract surgery and duration of use in patients with cataract surgery with and without diabetes.

Results

In the Netherlands, 9530 nepafenac users (mean age, 71 years; 60% women) contributed 12 691 therapy episodes, of which 21% had a recently recorded cataract surgery. Of 2266 episodes in adult non‐diabetic patients with cataract surgery, 60% had one bottle dispensed (treatment duration ≤21 days). Of 441 episodes in adult diabetic patients with cataract surgery, 90% had up to two bottles dispensed (≤60 days).

Denmark had 60 403 nepafenac users (mean age, 72 years; 58% women) and 73 648 episodes (41% had recorded cataract surgery). Of 26 649 nepafenac episodes in adult non‐diabetic patients with cataract surgery, 92% had one bottle dispensed. Of 3801 episodes in adult diabetic patients with cataract surgery, 99.8% had up to two bottles dispensed.

Use patterns of nepafenac, ketorolac and diclofenac were roughly similar in the Netherlands, but not in Denmark.

Conclusion

Less than half of therapy episodes were related to cataract surgery; around 90% of episodes with surgery were within the approved duration. Underrecording of ophthalmic conditions and procedures was a challenge in this study.

Non-steroidal anti-inflammatory drugs versus corticosteroids for controlling inflammation after uncomplicated cataract surgery

BACKGROUND

Cataract is a leading cause of blindness worldwide. Cataract surgery is commonly performed but can result in postoperative inflammation of the eye. Inadequately controlled inflammation increases the risk of complications. Non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids are used to prevent and reduce inflammation following cataract surgery, but these two drug classes work by different mechanisms. Corticosteroids are effective, but NSAIDs may provide an additional benefit to reduce inflammation when given in combination with corticosteroids. A comparison of NSAIDs to corticosteroids alone or combination therapy with these two anti-inflammatory agents will help to determine the role of NSAIDs in controlling inflammation after routine cataract surgery.

OBJECTIVES

To evaluate the comparative effectiveness of topical NSAIDs (alone or in combination with topical corticosteroids) versus topical corticosteroids alone in controlling intraocular inflammation after uncomplicated phacoemulsification. To assess postoperative best-corrected visual acuity (BCVA), patient-reported discomfort, symptoms, or complications (such as elevation of IOP), and cost-effectiveness with the use of postoperative NSAIDs or corticosteroids.

SEARCH METHODS

To identify studies relevant to this review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), which contains the Cochrane Eyes and Vision Trials Register (2016, Issue 12), MEDLINE Ovid (1946 to December 2016), Embase Ovid (1947 to 16 December 2016), PubMed (1948 to December 2016), LILACS (Latin American and Caribbean Health Sciences Literature Database) (1982 to 16 December 2016), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com; last searched 17 June 2013), ClinicalTrials.gov (www.clinicaltrials.gov; searched December 2016), and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en; searched December 2016).

SELECTION CRITERIA

We included randomized controlled trials (RCTs) in which participants were undergoing phacoemulsification for uncomplicated cataract extraction. We included both trials in which topical NSAIDs were compared with topical corticosteroids and trials in which combination therapy (topical NSAIDs and corticosteroids) was compared with topical corticosteroids alone. The primary outcomes for this review were inflammation and best-corrected visual acuity (BCVA).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the full-text articles, extracted data from included trials, and assessed included trials for risk of bias according to Cochrane standards. The two review authors resolved any disagreements by discussion. We graded the certainty of the evidence using GRADE.

MAIN RESULTS

This review included 48 RCTs conducted in 17 different countries and two ongoing studies. Ten included studies had a trial registry record. Fifteen studies compared an NSAID with a corticosteroid alone, and 19 studies compared a combination of an NSAID plus a corticosteroid with a corticosteroid alone. Fourteen other studies had more than two study arms. Overall, we judged the studies to be at unclear risk of bias. NSAIDs alone versus corticosteroids aloneNone of the included studies reported postoperative intraocular inflammation in terms of cells and flare as a dichotomous variable. Inflammation was reported as a continuous variable in seven studies. There was moderate-certainty evidence of no difference in mean cell value in the participants receiving an NSAID compared with the participants receiving a corticosteroid (mean difference (MD) -0.60, 95% confidence interval (CI) -2.19 to 0.99), and there was low-certainty evidence that the mean flare value was lower in the group receiving NSAIDs (MD -13.74, 95% CI -21.45 to -6.04). Only one study reported on corneal edema at one week postoperatively and there was uncertainty as to whether the risk of edema was higher or lower in the group that received NSAIDs (risk ratio (RR) 0.77, 95% CI 0.26 to 2.29). No included studies reported BCVA as a dichotomous outcome and no study reported time to cessation of treatment. None of the included studies reported the proportion of eyes with cystoid macular edema (CME) at one week postoperatively. Based on four RCTs that reported CME at one month, we found low-certainty evidence that participants treated with an NSAID alone had a lower risk of developing CME compared with those treated with a corticosteroid alone (RR 0.26, 95% CI 0.17 to 0.41). No studies reported on other adverse events or economic outcomes. NSAIDs plus corticosteroids versus corticosteroids aloneNo study described intraocular inflammation in terms of cells and flare as a dichotomous variable and there was not enough continuous data for anterior chamber cell and flare to perform a meta-analysis. One study reported presence of corneal edema at various times. Postoperative treatment with neither a combination treatment with a NSAID plus corticosteroid or with corticosteroid alone was favored (RR 1.07, 95% CI 0.98 to 1.16). We judged this study to have high risk of reporting bias, and the certainty of the evidence was downgraded to moderate. No included study reported the proportion of participants with BCVA better than 20/40 at one week postoperatively or reported time to cessation of treatment. Only one included study reported on the presence of CME at one week after surgery and one study reported on CME at two weeks after surgery. After combining findings from these two studies, we estimated with low-certainty evidence that there was a lower risk of CME in the group that received NSAIDs plus corticosteroids (RR 0.17, 95% CI 0.03 to 0.97). Seven RCTs reported the proportion of participants with CME at one month postoperatively; however there was low-certainty evidence of a lower risk of CME in participants receiving an NSAID plus a corticosteroid compared with those receiving a corticosteroid alone (RR 0.50, 95% CI 0.23 to 1.06). The few adverse events reported were due to phacoemulsification rather than the eye drops.

AUTHORS' CONCLUSIONS

We found insufficient evidence from this review to inform practice for treatment of postoperative inflammation after uncomplicated phacoemulsification. Based on the RCTs included in this review, we could not conclude the equivalence or superiority of NSAIDs with or without corticosteroids versus corticosteroids alone. There may be some risk reduction of CME in the NSAID-alone group and the combination of NSAID plus corticosteroid group. Future RCTs on these interventions should standardize the type of medication used, dosing, and treatment regimen; data should be collected and presented using the Standardization of Uveitis Nomenclature (SUN) outcome measures so that dichotomous outcomes can be analyzed.

Effect of topical nepafenac in prevention of macular edema after cataract surgery in patients with non-proliferative diabetic retinopathy

Objective:

To determine the efficacy of topical Nepafenac (0.1%), administered post-operatively in prevention of Macular Edema (ME), after cataract surgery in patients with Non-Proliferative Diabetic Retinopathy (NPDR).

Methods:

This randomized control trial was conducted at Armed Forces Institute of Ophthalmology (AFIO), Rawalpindi from Sep 2015 to Sep 2016. Sixty eyes of 60 patients with NPDR underwent phacoemulsification with intraocular lens implantation. Group 1 received 0.1% Nepafenac, 8-hourly, in operated eye after cataract surgery for three months, along with routine post-operative medications. Group-2 received only routine post-operative medications. ME was defined as increase in Central Macular Thickness (CMT) of >10% from pre-operative baseline, measured using spectral domain optical coherence tomography.

Results:

Mean age of study population was 60.97±4.91 years. Out of 60 patients, 34 (56.7%) were males and 24 (43.3%) were females. Mean pre-operative CMT, 3 months post-operative CMT, mean change in CMT and mean frequency change in CMT of Group-1 was 226.5±10.86µm, 228.83±14.56 µm, 2.33±10.45 µm and 1.05% respectively. Mean pre-operative CMT, three months post-operative CMT, mean change in CMT and mean frequency change in CMT in Group-2 was 223.93±11.69µm, 236.17±16.16 µm, 12.23±12.40µm and 5.51% respectively. ME was observed in one patient (3.3%) in Group-1, and seven patients (23.3%) in Group 2. The difference of mean change in CMT and frequency change in CMT between groups was statistically significant (p<0.05).

Conclusion:

0.1% topical Nepafenac is effective in prevention of macular edema after cataract surgery in patients with non-proliferative diabetic retinopathy (NPDR).

Prophylactic non-steroidal anti-inflammatory drugs for the prevention of macular oedema after cataract surgery

BACKGROUND

Macular oedema (MO) is the accumulation of extracellular fluid in the central retina (the macula). It may occur after cataract surgery and may give rise to poor visual outcome, with reduced visual acuity and distortion of the central vision. MO is often self-limiting with spontaneous resolution, but a small proportion of people with chronic persistent MO may be difficult to treat. Chronic oedema may lead to the formation of cystic spaces in the retina termed 'cystoid macular oedema' (CMO). Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used in cataract surgery and may reduce the chances of developing MO.

OBJECTIVES

The aim of this review is to answer the question: is there evidence to support the prophylactic use of topical NSAIDs either in addition to, or instead of, topical steroids postoperatively to reduce the incidence of macular oedema (MO) and associated visual morbidity.

SEARCH METHODS

We searched a number of electronic databases including CENTRAL, MEDLINE and Embase. Date last searched 2 September 2016.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in which adult participants had undergone surgery for age-related cataract. We included participants irrespective of their baseline risk of MO, in particular we included people with diabetes and uveitis. We included trials of preoperative and/or postoperative topical NSAIDs in conjunction with postoperative topical steroids. The comparator was postoperative topical steroids alone. A secondary comparison was preoperative and/or postoperative topical NSAIDs alone versus postoperative topical steroids alone.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, assessed risk of bias and extracted data using standard methods expected by Cochrane. We pooled data using a random-effects model. We graded the certainty of the evidence using GRADE and considered the following: risk of bias of included studies, precision of the effect estimate, consistency of effects between studies, directness of the outcome measure and publication bias.

MAIN RESULTS

We identified 34 studies that were conducted in the Americas, Europe, the Eastern Mediterranean region and South-East Asia. Over 5000 people were randomised in these trials. The majority of studies enrolled one eye per participant; a small subset (4 trials) enrolled a proportion of people with bilateral surgery. Twenty-eight studies compared NSAIDs plus steroids with steroids alone. Six studies compared NSAIDs with steroids. A variety of NSAIDs were used, including ketorolac, diclofenac, nepafenac, indomethacin, bromfenac, flurbiprofen and pranopfen. Follow-up ranged from one to 12 months. In general, the studies were poorly reported. We did not judge any of the studies at low risk of bias in all domains. Six studies were funded by industry, seven studies were funded from non-industry sources, and the rest of the studies did not report the source of funding.There was low-certainty evidence that people receiving topical NSAIDs in combination with steroids may have a lower risk of poor vision due to MO at three months after cataract surgery compared with people receiving steroids alone (risk ratio (RR) 0.41, 95% confidence interval (CI) 0.23 to 0.76; eyes = 1360; studies = 5; I2 = 5%). We judged this to be low-certainty evidence because of risk of bias in the included studies and indirectness, as the extent of visual loss was not always clear. Only one study reported poor vision due to MO at 12 months and we judged this to be very low-certainty evidence as there were only two events. Quality of life was only reported in one of the 34 studies comparing NSAIDs plus steroids versus steroids alone, and it was not fully reported, other than to comment on lack of differences between groups. There was evidence of a reduced risk of MO with NSAIDs at three months after surgery, but we judged this to be low-certainty due to risk of bias and publication bias (RR 0.40, 95% CI 0.32 to 0.49; eyes = 3638; studies = 21). There was inconsistent evidence on central retinal thickness at three months (I2 = 87%). Results ranged from -30.9 µm in favour of NSAIDs plus steroids to 7.44 µm in favour of steroids alone. Similarly, data on best corrected visual acuity (BCVA) were inconsistent, but nine out of 10 trials reporting this outcome found between-group differences in visual acuity of less than 0.1 logMAR.None of the six studies comparing NSAIDs alone with steroids reported on poor vision due to MO at three or 12 months. There was low-certainty evidence that central retinal thickness was lower in the NSAIDs group at three months (mean difference (MD) -22.64 µm, 95% CI -38.86 to -6.43; eyes = 121; studies = 2). Five studies reported on MO and showed a reduced risk with NSAIDs, but we judged this evidence to be of low-certainty (RR 0.27, 95% CI 0.18 to 0.41; eyes = 520). Three studies reported BCVA at three months and the results of these trials were inconsistent, but all three studies found differences of less than 0.1 logMAR between groups.We did not note any major adverse events - the main consistent observation was burning or stinging sensation with the use of NSAIDs.

AUTHORS' CONCLUSIONS

Using topical NSAIDs may reduce the risk of developing macular oedema after cataract surgery, although it is possible that current estimates as to the size of this reduction are exaggerated. It is unclear the extent to which this reduction has an impact on the visual function and quality of life of patients. There is little evidence to suggest any important effect on vision after surgery. The value of adding topical NSAIDs to steroids, or using them as an alternative to topical steroids, with a view to reducing the risk of poor visual outcome after cataract surgery is therefore uncertain. Future trials should address the remaining clinical uncertainty of whether prophylactic topical NSAIDs are of benefit, particularly with respect to longer-term follow-up (at least to 12 months), and should be large enough to detect reduction in the risk of the outcome of most interest to patients, which is chronic macular oedema leading to visual loss.

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.

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

PURPOSE

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

DESIGN

Systematic review and meta-analysis.

METHODS

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

STUDY POPULATION

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

OBSERVATION PROCEDURES

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

The Effects of Two Non-Steroidal Anti-Inflammatory Drugs, Bromfenac 0.1% and Ketorolac 0.45%, on Cataract Surgery

PURPOSE

To compare the additive effects of two types of non-steroidal anti-inflammatory drugs (NSAIDs), bromfenac 0.1% or ketorolac 0.45%, relative to topical steroid alone in cataract surgery.

MATERIALS AND METHODS

A total 91 subjects scheduled to undergo cataract operation were randomized into three groups: Group 1, pre/postoperative bromfenac 0.1%; Group 2, pre/postoperative preservative-free ketorolac 0.45%; and Group 3, postoperative steroid only, as a control. Outcome measures included intraoperative change in pupil size, postoperative anterior chamber inflammation control, change in macular thickness and volume, and ocular surface status after operation.

RESULTS

Both NSAID groups had smaller intraoperative pupil diameter changes compared to the control group (p<0.05). There was significantly less ocular inflammation 1 week and 1 month postoperatively in both NSAID groups than the control group. The changes in central foveal subfield thickness measured before the operation and at postoperative 1 month were 4.30±4.25, 4.87±6.03, and 12.47±12.24 μm in groups 1 to 3, respectively. In the control group, macular thickness and volume increased more in patients with diabetes mellitus (DM), compared to those without DM. In contrast, in both NSAID groups, NSAIDs significantly reduced macular changes in subgroups of patients with or without DM. Although three ocular surface parameters were worse in group 1 than in group 2, these differences were not significant.

CONCLUSION

Adding preoperative and postoperative bromfenac 0.1% or ketorolac 0.45% to topical steroid can reduce intraoperative miosis, postoperative inflammation, and macular changes more effectively than postoperative steroid alone.

Management of mydriasis and pain in cataract and intraocular lens surgery: review of current medications and future directions

The maintenance of mydriasis and the control of postoperative pain and inflammation are critical to the safety and success of cataract and intraocular lens replacement surgery. Appropriate mydriasis is usually achieved by topical and/or intracameral administration of anticholinergic agents, sympathomimetic agents, or both, with the most commonly used being cyclopentolate, tropicamide, and phenylephrine. Ocular inflammation is common after cataract surgery. Topical steroids and nonsteroidal anti-inflammatory drugs are widely used because they have been proved effective to control postsurgical inflammation and decrease pain. Topical nonsteroidal anti-inflammatory drugs have also been shown to help maintain dilation. However, use of multiple preoperative drops for pupil dilation, inflammation, and pain control have been shown to be time consuming, resulting in delays to the operating room, and they cause dissatisfaction among perioperative personnel; their use can also be associated with systemic side effects. Therefore, ophthalmologists have been in search of new options to streamline this process. This article will review the current medications commonly used for intraoperative mydriasis, as well as pain and inflammation control. In addition, a new combination of ketorolac, an anti-inflammatory agent, and phenylephrine, a mydriatic agent has recently been designed to maintain intraoperative mydriasis and to reduce postoperative pain and irritation from intraocular lens replacement surgery. Two Phase III clinical trials evaluating this combination have demonstrated statistically significant differences when compared to placebo in maintaining intraoperative mydriasis (P<0.00001) and in reducing pain in the early postoperative period (P=0.0002). This medication may be of benefit for use in cataract and lens replacement surgery in the near future.

Prophylactic postoperative ketorolac improves outcomes in diabetic patients assigned for cataract surgery

Objective

To evaluate the prophylactic role of topical non-steroidal anti-inflammatory drugs in reducing the incidence of central macular edema (CME) in diabetic eyes post-cataract surgery.

Patients and methods

This study included 86 eyes (70 patients) with high risk characteristics for the development of CME after cataract surgery. All patients underwent phacoemulsification and intraocular lens implantation. Patients were divided into two equal groups (n = 43 [eyes]): a control group given topical dexamethasone 0.1%, four times/day for 12 weeks postoperatively and a study group given topical ketorolac tromethamine 0.4% twice daily in addition to topical dexamethasone 0.1% four times daily for 12 weeks. Patients were examined at 3, 6, and 12 weeks postoperatively for evaluation of CME development. The main study outcome was the change in the retinal fovea thickness measured with ocular coherence topography.

Results

Ten eyes developed CME (11.6%); eight eyes in the control group and only two eyes in the study group. Mean retinal fovea thickness was significantly higher in the control group compared to the study group. Moreover, eyes of the control group developed CME significantly earlier than those of the study group.

Conclusion

Prophylactic postoperative ketorolac 0.4% may have a role in reducing the frequency and severity of CME in diabetic eyes post-cataract surgery.

Effect of preoperative use of topical prednisolone acetate, ketorolac tromethamine, nepafenac and placebo, on the maintenance of intraoperative mydriasis during cataract surgery: a randomized trial

Purpose:

To compare the effects of preoperative use of topical anti-inflammatory prednisolone acetate, ketorolac tromethamine, nepafenac and placebo, on the maintenance of intraoperative mydriasis during cataract surgery.

Design:

Randomized clinical trial.

Materials and Methods:

This single-center, masked, randomized clinical study comprised 140 patients scheduled for cataract surgery. Patients (35 in each group) were randomized to receive placebo, prednisolone acetate, ketorolac tromethamine 0.4% or nepafenac. These eye drops were administered three times daily for the two days prior to surgery. The pupillary diameters were measured by the surgeon using a compass prior to the corneal section and at the end of surgery. The primary outcome was the number of patients with pupil ≥ 6mm at the end of the surgery; the secondary outcome was the number of patients with pupil ≥ 6mm at the beginning of the surgery.

Results:

All the patients achieved pupil ≥ 6mm at the beginning of the surgery. The number of patients in the prednisolone (29/35), nepafenac (31/35) and ketorolac (30/35) groups with pupil ≥ 6mm was greater than in the placebo group in the maintenance of intraoperative mydriasis (19/35 – P =0.003). There was no statistical difference among the prednisolone, nepafenac and ketorolac groups in the maintenance of intraoperative mydriasis (P =.791). There were no complications during surgery or related to the preoperative use of the eye drops.

Conclusion:

Preoperative use of ketorolac, prednisolone and nepafenac was effective in maintaining intraoperative mydriasis when compared with placebo.

Effect of fentanyl versus buprenorphine on the pupil size in phacoemulsification cataract surgery

BACKGROUND

Despite several recent innovations in phacoemulsification surgery, importance of pupil diameter in this surgery is becoming more evident.

PURPOSE

To compare the effect of opioid agonist (fentanyl) versus opioid agonist-antagonist (buprenorphine) on pupil diameter in cataract surgery and to choose the best opioid in high-risk phacoemulsification surgery.

METHODS

In this randomized double-blinded clinical trial, 60 patients who were candidates for elective phacoemulsification surgery were randomly divided into two equal groups: experimental (buprenorphine, 0.3 μg/kg) and control (fentanyl, 1 μg/kg). Pupil diameter was measured preinjection and at several times postinjection. Blood pressure was recorded at several intervals, as well as shivering, nausea and vomiting, and recovery time.

RESULTS

Mean (SD) recovery time was significantly less in the control group (19.46±5.43) than in the experimental group (33.23±10.75) (P<0.0001). The constriction effect (ie, pupillary diameter in mm) was significantly lower in the experimental group (0.53±0.45) than in the control group (1.06±0.52) (P=0.0001). The percentages of constriction effect in experimentaland control groups were 7.68% and 15.07%, respectively. The eye was two times more constricted in the control group in comparison with the experimental group after induction of anesthesia.

CONCLUSION

Buprenorphine is a better solution to decrease pupil constriction in comparison with fentanylinhigh-risk phacoemulsification surgery.