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

A meta-analysis of topical Ketorolac's effect on surgical site wound healing post-cataract surgery

This meta-analysis evaluates the impact of topical ketorolac on surgical site wound healing and scar formation after cataract surgery. A thorough literature search, adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, identified eight relevant studies from 2348 articles. The selected studies were analysed for wound healing efficacy, using the redness, edema, ecchymosis, discharge and approximation (REEDA) scale, and scar formation, assessed by the Manchester scar scale (MSS). Results indicated that ketorolac significantly improved wound healing, with lower REEDA scores 1 week post-surgery (I2  = 97%; Random: standardised mean difference (SMD): -10.93, 95% CI: -13.85 to -8.00, p < 0.01), and reduced scar formation, evidenced by lower MSS scores 3 months post-surgery (I2  = 74%; Random: SMD: -9.67, 95% CI: -11.03 to -8.30, p < 0.01). The findings suggest that topical ketorolac is beneficial in post-cataract surgery care, enhancing wound healing and reducing scarring.

Comparison of postcataract surgery anti-inflammatory regimens on the incidence of cystoid macular edema, iritis, pain, and photophobia

PURPOSE

To compare postcataract surgery anti-inflammatory regimens of intracanalicular dexamethasone insert and topical bromfenac on the incidence of cystoid macular edema (CME), iritis, pain, and photophobia.

SETTING

Eyes of York Cataract & Laser Center, York, Pennsylvania.

DESIGN

Retrospective chart review.

METHODS

Case records of 647 consecutive patients (1001 eyes) who underwent cataract surgery and received dexamethasone intracanalicular insert 0.4 mg (Group 1; 482 eyes) or topical nonsteroidal anti-inflammatory drug (NSAID) (bromfenac 0.075% 2 times a day) for 4 weeks postoperatively (Group 2; 519 eyes) were included. Both groups received intracameral moxifloxacin and phenylephrine/ketorolac. Patients with prior CME, vitreomacular traction, combined cataract/glaucoma surgery, and medication protocols different from those examined in this study were excluded.

RESULTS

Compared with the dexamethasone insert group, the topical NSAID group had a significantly lower incidence of CME (0.4% [2/519] vs 3.9% [19/482], P < .001) and photophobia (1.9% [10/519] vs 4.8% [23/482], P = .012). The incidence of breakthrough iritis (3.5% [18/519] vs 5.6% [27/482], P = .104) and pain also trended lower (4.0% [21/519] vs 5.4% [26/482], P = .314) in the topical NSAID group.

CONCLUSIONS

Topical NSAIDs were found to be more effective in controlling CME, pain, iritis, and photophobia after cataract surgery compared with the intracanalicular dexamethasone insert in the presence of intracameral phenylephrine/ketorolac.

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.

Nano-engineering of ketorolac tromethamine platforms for ocular treatment of inflammatory disorders

Aim: The development and optimization of Ketorolac tromethamine-loaded polylactic-co-glycolic acid nanoparticles (KT-NPs) for the treatment of inflammatory processes of the eye. Materials & methods: KT-NPs were developed by factorial design and characterized by assessing their physicochemical properties. Biopharmaceutical behavior studies, ocular tolerance, anti-inflammatory efficacy and bioavailability tests were performed on pigs. Results: Optimized KT-NPs of 112 nm, narrow distribution with encapsulation efficiency near 100% were obtained. KT release followed the Weibull model and there was significantly greater retention in the cornea and sclera than in the commercial reference. KT-NPs showed no signs of ocular irritancy and similar anti-inflammatory efficacy to the commercial reference. Conclusion: KT-NPs were a suitable alternative for the treatment of inflammatory disorders of the anterior and posterior segments of the eye as an alternative to conventional topical formulations.

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.

Pharmacotherapeutic management of macular edema in diabetic subjects undergoing cataract surgery

INTRODUCTION

Cataracts and diabetes are widespread pathologies that are of growing concern to the global population. In diabetic patients who have had cataract surgery, the worsening of preexisting diabetic macular edema or occurrence of pseudophakic cystoid macular edema are common causes of visual impairment even with the most advanced surgical techniques available today for phacoemulsification.

AREAS COVERED

In this review, the authors assess the available literature to evaluate and compare different drugs, with the aim of establishing the best pharmacological strategies for the prevention and treatment of macular edema in diabetic patients undergoing cataract surgery.

EXPERT OPINION

Guidelines for the optimal management of diabetic macular edema in conjunction with cataract surgery or treatment of pseudophakic cystoid macular edema in diabetic patients are still lacking. To treat these conditions, clinicians need to understand the pharmacokinetics, posology, and efficacy of available drugs: topical non-steroidal anti-inflammatory drugs (NSAIDs), intravitreal anti-vascular endothelial growth factors (VEGFs), and both topical and intravitreal steroids. Diabetic patients undergoing cataract surgery should receive topical NSAIDs to prevent pseudophakic cystoid macular edema. Intravitreal anti-VEGFs and steroids, in association with cataract surgery, are indicated for patients with preexisting diabetic macular edema or those at high risk of macular edema after surgery.

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.

2D-SAR and 3D-QSAR analyses for acetylcholinesterase inhibitors

Alzheimer's disease (AD) accounts for almost three quarters of dementia patients and interferes people's normal life. Great progress has been made recently in the study of Acetylcholinesterase (AChE), known as one of AD's biomarkers. In this study, acetylcholinesterase inhibitors (AChEI) were collected to build a two-dimensional structure-activity relationship (2D-SAR) model and three-dimensional quantitative structure-activity relationship (3D-QSAR) model based on feature selection method combined with random forest. After calculation, the prediction accuracy of the 2D-SAR model was 89.63% by using the tenfold cross-validation test and 87.27% for the independent test set. Three cutting ways were employed to build 3D-QSAR models. A model with the highest [Formula: see text] (cross-validated correlation coefficient) and [Formula: see text](non-cross-validated correlation coefficient) was obtained to predict AChEI activity. The mean absolute error (MAE) of the training set and the test set was 0.0689 and 0.5273, respectively. In addition, molecular docking was also employed to reveal that the ionization state of the compounds had an impact upon their interaction with AChE. Molecular docking results indicate that Ser124 might be one of the active site residues.

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.

Topical bromfenac for prevention and treatment of cystoid macular edema following cataract surgery: a review

Topical nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids, alone or in combination, have historically been used off label in the US to prevent and treat postoperative cystoid macular edema (CME). This literature review presents available data on the use of bromfenac 0.07% or 0.09% to prevent and treat CME following cataract surgery. Bromfenac is an NSAID approved to treat postoperative inflammation and reduce ocular pain following cataract surgery. Few cases of clinical CME were observed with bromfenac use in a total of 19 reviewed studies. There were no significant differences in CME incidence between bromfenac and corticosteroid-treated patients or between bromfenac- and bromfenac plus corticosteroid-treated patients. Bromfenac demonstrated comparable efficacy to other NSAIDs in preventing CME. Compared with corticosteroids, bromfenac alone or plus a corticosteroid showed similar or better efficacy in minimizing changes in retinal thickness and macular volume. In diabetic cataract surgery patients, bromfenac was comparable or superior to corticosteroids for minimizing changes in retinal thickness; also, combination therapy with bromfenac and corticosteroids may be associated with smaller changes in foveal thickness, macular thickness, and macular volume versus monotherapy with either treatment alone in this patient population. In two randomized, double-masked, placebo-controlled clinical trials with bromfenac 0.07%, CME was reported as an adverse event in 0.5% and 1.5% of patients receiving bromfenac and placebo, respectively. In an analysis of four placebo-controlled trials with bromfenac 0.09%, macular edema was reported in 0.7% and 1.4% of patients receiving bromfenac and placebo, respectively. When evaluated as treatment for acute or chronic CME, bromfenac was associated with improvement in visual acuity and reduction in retinal thickness, but few studies are available. Overall, published data suggest that bromfenac is safe and effective when used to prevent or treat CME. Large-scale placebo-controlled trials and greater standardization of CME measures are needed to establish optimal bromfenac regimens for the prophylaxis and treatment of CME following cataract surgery.