The Influence of Topical Perioperative Nepafenac on Retinal Vasculature Following Phacoemulsification Using Optical Coherence Tomography Angiography: A Randomized Clinical Trial

PURPOSE

To investigate topical nepafenac drops (TND) effect on retinal vasculature following uneventful phacoemulsification.

METHODS

54 eyes were randomly assigned to G1: TND 3 days preoperatively and 1 month postoperatively; G2: TND for 1 month postoperatively; and G3 no TND (control). BCVA, macular OCTA were compared baseline, 1 week and 1 month.

RESULTS

No statistically significant differences found between 3 groups in OCTA parameters during study visits. However, at 1 month (compared to baseline) there were a statistically significant increase in superficial capillary plexus (SCP) capillary vessel density (CVD) in G2 (p=0.036); increase in central foveal thickness (CFT) in G2 (p=0.011) and G3 (control) (p=0.001); and reduced number of patients with SCP disorganization in G2 (p=0.04). There were no significant correlation/association between most of OCTA parameters and final BCVA.

CONCLUSION

TND use perioperative did not show any effect on retinal OCTA microvasculature and might affect macular edema by other mechanisms.

OCT imaging of macular cysts and treatment response with nepafenac in mucopolysaccharidosis type 1

PURPOSE

Mucopolysaccharidosis Type I (MPS I) is an autosomal recessive lysosomal storage disorder characterized by a defect in the enzyme alpha-L-iduronidase. Glycosaminoglycan accumulation causes ocular involvement such as corneal clouding or pigmentary retinopathy. Here we report bilateral macular cysts in mucopolysaccharidosis type I (MPS I) that responds to nepafenac treatment.

METHODS

Retrospective case report.

RESULTS

A 27-year-old woman with MPS I (Scheie phenotype) was complaining of slightly blurred vision. She had been on alpha-L-iduronidase enzyme replacement therapy for ten years. Best-corrected visual acuity was 20/25 in both eyes. Biomicroscopy was normal. Dilated fundus examination revealed pigmentary retinopathy. Optical coherence tomography (OCT) detected macular cysts in inner and outer nuclear layers, with preservation of ellipsoid zone and IS/OS line. There was no dye leakage on fluorescein angiography. Macular cysts regressed partially after one month with topical nepafenac 0.1% four times a day. BCVA improved to 20/20 in both eyes.

CONCLUSIONS

This is the first report of bilateral macular cysts that was demonstrated with OCT and treated with topical nepafenac in a patient with MPS I. Because the symptoms of our patient were mild, large-scaled cohort studies are required to ascertain the real prevalence of macular cysts in MPS I. It may also be beneficial to do more research on the possible benefits of nepafenac on the retinal manifestations of MPS.

Comparison of once daily dose of 0.3% nepafenac alone and three times dose of 0.1% nepafenac alone in pain and inflammation control after phacoemulsification

Purpose:

To compare the efficacy of a once-daily dose of 0.3% nepafenac and three times daily dose of 0.1% nepafenac in controlling pain and inflammation following phacoemulsification.

Methods:

In this prospective randomized control single-blind study. patients who underwent uneventful phacoemulsification were divided into two groups. Group A received 0.1% nepafenac eye drops three times/day for 4 weeks and group B received 0.3% nepafenac eye drops once daily for 4 weeks following phacoemulsification. All the patients received moxifloxacin 0.5% eye drops four times/day for 2 weeks. None of the patients in any group received any form of corticosteroids.

Results:

The mean age of the patients in group A was 63.55 ± 8.5 years, while in group B, it was 60.05 ± 7.76 years. There was no significant result in the preoperative baseline demographics and intraoperative parameters between both the groups. The results were statistically insignificant in terms of inflammatory markers between both groups on day 1. But, on day 7, group B showed better results in terms of lid edema, conjunctival congestion, and anterior chamber cells. The patients in group B also perceived significantly less pain on day 1 (P = 0.02) and day 7 (P < 0.001). The central macular thickness was also significantly lower in group B at day 30 (P < .001) and day 90 (P < .001), respectively.

Conclusion:

Once-daily dose of higher concentrated nepafenac (0.3%) is equally effective and shows better results than 0.1% nepafenac for pain and inflammation control.

A prospective randomized clinical trial comparing nepafenac, intravitreal triamcinolone and no adjuvant therapy for epiretinal membrane

PURPOSE

To compare the efficacy of topical nepafenac 0.1% versus intravitreal triamcinolone acetonide (IVTA) at the conclusion of vitrectomy surgery versus no adjuvant therapy (NAT) in improving macular morphology post-operatively in patients undergoing vitrectomy for epiretinal membrane (ERM), as measured by optical coherence tomography (OCT) imaging and best-corrected visual acuity (BCVA).

METHODS

Design: Prospective randomized clinical trial Setting: Multi-centre 80 patients scheduled to undergo vitrectomy surgery for idiopathic ERM were randomized to receive either IVTA (4 mg/0.1 cc) at the end of surgery, topical nepafenac sodium 0.1% TID for 1 month post-operation or no adjuvant treatment (NAT). Optical coherence tomography (OCT) imaging, best-corrected visual acuity and intraocular pressure (IOP) were measured before surgery, and 1 and 2 months post-operation.

RESULTS

Although all three groups showed reduction in macular thickness post-operation, the NAT group showed the most improvement, with a reduction of 136.18 ± 29.84 μm at two months. There was no statistically significant difference in macular thickness between the groups at each time point, p = 0.158. The NAT group also had the best recovery in BCVA with an improvement of 0.207 logMAR (10.35 letters) at two months post-operation. There was no statistically significant difference in BCVA between the groups, p = 0.606. There was statistically significant difference in the IOP between the three groups, p = 0.04 only at 1-month visit. The IVTA group had the highest rise in average IOP at both 1 and 2 months post-operation (2.72 and 1.58 mmHg, respectively).

CONCLUSION

Our study data suggest there was no advantage in the use of topical nepafenac or IVTA for post-vitrectomy ERM surgery.

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.

Effect of nepafenac 0.1% on retinal thickness after cataract surgery in patients without risk factors for cystoid macular edema

AIM

To evaluate the effect of topical preoperative nepafenac 0.1% treatment on postoperative macular edema using optical coherence tomography (OCT) after uncomplicated cataract surgery.

METHODS

Ninety eyes of 90 patients without any risk factors were included in the study. The patients were assigned to three groups: group 1, treated with topical prednisolone acetate 1%; group 2, treated with topical nepafenac 0.1% in addition to prednisolone acetate (1%); and group 3, those who started receiving nepafenac 0.1% treatment 3d prior to surgery and continued the treatment postoperatively in addition to prednisolone acetate (1%). Central retinal thickness (CRT) and macular volume values were recorded using OCT at weeks 3 and 6.

RESULTS

The increases in macular volume in the central 1 mm area after 3 and 6wk were significantly lower in patients who used prophylactic topical nepafenac preoperatively (group 3) compared with those in group 1 (P=0.028 and 0.008, respectively). No significant differences in the increase in macular volume and CRT were noted between groups 2 and 3 (P>0.05). In group 1, the increases in macular volume in the central 3 mm area at weeks 3 and 6 were significantly higher than that in group 2 and 3 (3^rd week, P=0.004; 6^th week, P=0.005).

CONCLUSION

Nepafenac 0.1% treatment in addition to topical steroids after uncomplicated cataract surgery reduce the increase in macular volume in the early postoperative period.

Efficacy of Topical Nepafenac 0.3% in the Management of Postoperative Cystoid Macular Edema

Purpose

To assess the effect of twice-daily nepafenac ophthalmic suspension 0.3% on postoperative cystoid-macular-edema (CME).

Patients and Methods

In this prospective, clinic-based, non-randomized case-series, 21 patients (21 eyes) were enrolled with either acute or chronic postoperative CME after cataract extraction. Patients were treated with twice-daily nepafenac 0.3% drops, and followed for at least a 4-month period. Best-corrected visual acuity (BCVA) and spectral-domain optical coherence tomography (SD-OCT)-derived central retinal thickness (CRT) were measured.

Results

From 21 patients, eight presented with acute postoperative CME and 13 with chronic CME. Mean follow-up was 4.82±1.24 months. No adverse events were reported during the study. Baseline BCVA was 0.49±0.36 logMAR and improved to 0.36±0.42 logMAR at the last follow-up visit (P<0.005). CRT decreased from 450.40±90.74 μm at baseline to 354.60±81.49 μm (P<0.05), following treatment.

Conclusion

Our outcomes strongly suggest that administrating nepafenac 0.3% drops on a twice-daily regimen could be a promising alternative for the management of postoperative CME. Additional studies are necessary to further validate our results.

In Vitro and Ex Vivo Evaluation of Nepafenac-Based Cyclodextrin Microparticles for Treatment of Eye Inflammation

The aim of this study was to design and evaluate novel cyclodextrin (CD)-based aggregate formulations to efficiently deliver nepafenac topically to the eye structure, to treat inflammation and increase nepafenac levels in the posterior segment, thus attenuating the response of inflammatory mediators. The physicochemical properties of nine aggregate formulations containing nepafenac/γ-CD/hydroxypropyl-β (HPβ)-CD complexes as well as their rheological properties, mucoadhesion, ocular irritancy, corneal and scleral permeability, and anti-inflammatory activity were investigated in detail. The results were compared with a commercially available nepafenac suspension, Nevanac^® 3 mg/mL. All formulations showed microparticles, neutral pH, and negative zeta potential (–6 to –27 mV). They were non-irritating and nontoxic and showed high permeation through bovine sclera. Formulations containing carboxymethyl cellulose (CMC) showed greater anti-inflammatory activity, even higher than the commercial formulation, Nevanac^® 0.3%. The optimized formulations represent an opportunity for topical instillation of drugs to the posterior segment of the eye.

Treatment of central serous chorioretinopathy with topical NSAIDs

Purpose

Central serous chorioretinopathy (CSCR) is a common retinopathy that is often observed until resolution. The purpose of this study is to evaluate the effects of topical nonsteroidal anti-inflammatory drugs (NSAIDs) on timing of CSCR recovery.

Methods

An IRB-approved retrospective review was conducted on patients that had been diagnosed with a new-onset, symptomatic case of CSCR. Patients were either observed only (13 untreated eyes) or treated with topical bromfenac or nepafenac (14 eyes) over an average of about a 4-5 week follow-up period.

Results

There was no statistical significance between central macular thickness (CMT) and visual acuity of treatment and control groups at the initial presentation. However, at the follow-up visit, CMT reductions in the treatment group were significantly higher than in the control group (p<0.006).

Conclusion

Use of topical NSAIDs in the treatment of acute CSCR leads to a faster rate of reduction in the subretinal fluid volume over a follow-up period of a few weeks.

Evaluation effectiveness of 0.1% nepafenac on injection-related pain in patients undergoing intravitreal Ozurdex injection

Purpose:

To evaluate the analgesic effect of topical 0.1% nepafenac solution during intravitreal Ozurdex injection.

Methods:

This prospective, randomized, double-blind placebo-controlled study included 59 patients who were diagnosed with retinal vein occlusion or pseudophakic cystoid macular edema and were selected to receive intravitreal Ozurdex injection. The patients were divided into two groups. Group 1, consisting of 31 eyes of 31 patients, received topical 0.1% nepafenac with topical anesthesia (0.5% proparacaine HCl, Alcaine; Alcon, TX, USA), and group 2, consisting of 28 eyes of 28 patients, received placebo with topical anesthesia.

Results:

There were 14 (45.2%) men and 17 (54.8%) women in group 1 and 16 (57.1%) men and 12 (42.9%) women in group 2. The mean age of the subjects was 64.42 ± 5.51 years in group 1 and 62.32 ± 7.54 years in group 2. The median visual analog scale pain score was 2 (1–3) in group 1 and 4 (1–6) in group 2. The visual analog scale pain score was significantly lower in group 1 than in group 2 (p < 0.001).

Conclusion:

Topical 0.1% nepafenac has an additive analgesic effect when combined with topical anesthesia for intravitreal Ozurdex injection.

Functional and anatomical evaluation of the effect of nepafenac in prevention of macular edema after phacoemulsification in diabetic patients

AIM

To evaluate the effect of prophylactic administration of nepafenac in prevention of macular edema occurring in diabetic patients after phacoemulsification and to investigate the correlation between optical coherence tomography (OCT) foveal thickness and multifocal electroretinogram (MF-ERG) parameters.

METHODS

The study included two groups. Group 1 included 50 diabetic patients with senile cataract (50 eyes, 30 females, 20 males, aged 55±7y) received nepafenac 0.1% eye drop. Group 2 included another 50 diabetic patients with senile cataract (50 eyes, 22 female, 28 males, aged 53.8±8y) did not receive nepafenac. All patients were followed up for 3mo postoperatively. OCT and MF-ERG were done preoperative and at 1wk, 1, 2 and 3mo.

RESULTS

The mean foveal thickness was statistically significantly lower in Group 1. Five eyes in Group 2 developed clinical cystoid macular oedema (CMO) (10%), and no patients in Group 1 developed central macular thickening more than 50 µm. There were insignificant differences in MF-ERG amplitudes and latencies between the two groups except in the five eyes that developed CMO, there statistically significant reduction of MF-ERG amplitude with increase in foveal thickness.

CONCLUSION

Perioperative nepafenac reduces the incidence of CMO following uncomplicated phacoemulsification significantly. Nepafenac has no side effects.

Comparison of topical nepafenac 0.1% with intravitreal dexamethasone implant for the treatment of Irvine-Gass syndrome

AIM

To compare safety and efficacy of intravitreal dexamethasone (IVD) implant with topical nepafenac (TN) 0.1% in previously untreated Irvine-Gass syndrome (IGS) in clinical practice.

METHODS

This was a retrospective study of 62 eyes with IGS after phacoemulsification with posterior chamber intraocular lens (IOL) implantation. None of the patients used treatment before IVD or TN. Best-corrected visual acuity (BCVA) with Early Treatment Diabetic Retinopathy Study chart (ETDRS), slit-lamp, intraocular pressure (IOP) measurement, fundus examination, spectral-domain optical coherence tomography (OCT) and fundus florescein angiography were performed to all subjects at baseline, 1, 3 and 6mo.

RESULTS

The mean BCVA of the IVD group was 49.3±6.8, and the mean BCVA of the TN group was 32.9±7.3 ETDRS letters in post-treatment month 6. The mean central macular thickness (CRT) of IVD group was 266.6±53.5 µm and the mean CRT of TN group was 364.9±56.3 µm in post-treatment month 6. Baseline BCVA has correlation with final BCVA in TN group however there was no correlation between baseline BCVA and final BCVA in IVD group.

CONCLUSION

IVD is found to be better than TN in controlling pseudophakic macular edema and improving visual acuity. IVD group also has significantly lower CRT however IOP is not significantly different between two groups in post-treatment month 6.

Nepafenac-Loaded Cyclodextrin/Polymer Nanoaggregates: A New Approach to Eye Drop Formulation

The topical administration route is commonly used for targeting therapeutics to the eye; however, improving the bioavailability of drugs applied directly to the eye remains a challenge. Different strategies have been studied to address this challenge. One of them is the use of aggregates that are formed easily by self-assembly of cyclodextrin (CD)/drug complexes in aqueous solution. The aim of this study was to design a new eye drop formulation based on aggregates formed between CD/drug complexes. For this purpose, the physicochemical properties of the aggregates associated with six CDs and selected water-soluble polymers were analysed. Complex formation was studied using differential scanning calorimetry (DSC), Fourier-transform infrared spectroscopy (FT-IR) and ¹H nuclear magnetic resonance spectroscopy (¹H-NMR). Results showed that HPβCD performed best in terms of solubilization, while γCD performed best in terms of enhancing nanoaggregate formation. Formation of inclusion complexes was confirmed by DSC, FT-IR and ¹H-NMR studies. A mixture of 15% (w/v) γCD and 8% (w/v) HPβCD was selected for formulation studies. It was concluded that formulations with aggregate sizes less than 1 µm and viscosity around 10–19 centipoises can be easily prepared using a mixture of CDs. Formulations containing polymeric drug/CD nanoaggregates represent an interesting strategy for enhanced topical delivery of nepafenac.

In Situ Gel Formulation for Enhanced Ocular Delivery of Nepafenac

Nepafenac is a water-insoluble nonsteroidal antiinflammatory drug that is available as an ophthalmic suspension (Nevanac®). Suspensions are undesirable for 2 reasons: they tend to cause foreign body sensation and lacrimation, which could limit residence time and drug bioavailability. This decreases the amount of time the drug has to reach the site of action, the cornea. Previously, we improved the solubility and ocular permeability of nepafenac by complexing the drug with hydroxypropyl-β-cyclodextrin. In this study, we used the complex to formulate an ion-activated in situ gel system using sodium alginate, Protanal PH 1033, to increase the residence time and to reduce repeat eye drop instillation. Rheological properties of the formulations revealed that the viscosity of the optimized formulation was increased 30-fold when exposed to the simulated tear fluid (35°C). Permeation studies showed that the drug concentration of the in situ formulations were approximately 10 times higher than the commercial product, Nevanac® (p < 0.001). In addition, the in situ gel formulations had 5-fold higher concentrations of nepafenac retained in the cornea when compared to Nevanac® (p <0.001). Finally, ex vivo drug distribution studies in the porcine eye perfusion model revealed a higher drug retention in various ocular tissues such as cornea, sclera, retina, as compared to Nevanac®.

Improved Ocular Delivery of Nepafenac by Cyclodextrin Complexation

Nepafenac is a nonsteroidal anti-inflammatory drug (NSAID), currently only available as 0.1% ophthalmic suspension (Nevanac®). This study utilized hydroxypropyl-β-cyclodextrin (HPBCD) to increase the water solubility and trans-corneal permeation of nepafenac. The nepafenac-HPBCD complexation in the liquid and solid states were confirmed by phase solubility, differential scanning calorimetry (DSC), X-ray diffraction (XRD), Fourier transform infrared spectroscopy (FT-IR), and nuclear magnetic resonance spectroscopy (NMR) analyses. Nepafenac 0.1% ophthalmic solution was formulated using HPBCD (same pH and osmolality as that of Nevanac®) and pig eye trans-corneal permeation was studied versus Nevanac®. Furthermore, nepafenac content in cornea, sclera, iris, lens, aqueous humor, choroid, ciliary body, retina, and vitreous humor was studied in a continuous isolated pig eye perfusion model in comparison to the suspension and Nevanac®. Permeation studies using porcine corneas revealed that the solution formulation had a permeation rate 18 times higher than Nevanac®. Furthermore, the solution had 11 times higher corneal retention than Nevanac®. Drug distribution studies using porcine eyes revealed that the solution formulation enables detectable levels in various ocular tissues while the drug was undetectable by Nevanac®. The ocular solution formulation had a significantly higher drug concentration in the cornea compared to the suspension or Nevanac®.

Comparative study of the efficacy and safety of bromfenac, nepafenac and diclofenac sodium for the prevention of cystoid macular edema after phacoemulsification

AIM

To compare the efficacy, tolerability and safety of bromfenac 0.09%, nepafenac 0.1% or diclofenac 0.1% for the prophylaxis of the cystoid macular edema (CME) after phacoemulsification.

METHODS

Group sequential observational comparative study. After phacoemulsification, patients received two months for topical treatment of either diclofenac sodium, bromfenac or nepafenac. All patients received concomitant topical tobramycin 0.3% and topical prednisolone 1%. We measured CME using optical coherence tomography (OCT) central foveal thickness, macular thickness and total macular volume.

RESULTS

We enrolled 243 patients from January to June 2015, and 35% received diclofenac, 32.9% bromfenac and 32.1% nepafenac. When we compared pre-operative to three weeks to two months, bromfenac was more effective in reducing foveal volume (21.3 and 35.4 mm³, respectively), compared with the diclofenac (1.3 and 11.5 mm³, respectively), and the nepafenac group, became more edematous 6.4 and 5.3, respectively. Totally 133 patients completed the post-surgical satisfaction questionnaire. Patients complained of eye stickiness in 13.8% whom we gave nepafenac, versus 10.3% whom we gave diclofenac sodium, and in 0 whom we gave bromfenac.

CONCLUSION

Bromfenac is the best tolerated and is more effective than diclofenac and nepafenac in reducing CME after phacoemulsification.

Impact of topical nonsteroidal anti-inflammatory drugs in prevention of macular edema following cataract surgery in diabetic patients

AIM

To evaluate the efficacy of prophylactic administration of topical non-steroidal anti-inflammatory drugs (NSAIDs) on macular edema following cataract surgery in diabetic patients, and to compare between types of NSAIDs (ketorolac tromethamine 0.4% and nepafenac 0.1%).

METHODS

Group 1 (control) received artificial tears substitute as a placebo group, group 2 (nepafenac) received topical nepafenac 0.1%, and group 3 (ketorolac) received topical ketorolac tromethamine 0.4%. Patients were examined postoperatively after completing one week, one month, two months and three months' intervals for evaluating cystoid macular edema (CME) development. The main study outcomes were achieving the best corrected visual acuity (BCVA) and change in the central macular thickness (CMT) measured with optical coherence topography (OCT).

RESULTS

Eighty eyes of 76 patients were included in this study. BCVA showed a statistically significant difference at the third month postoperative follow up between the control group and the NSAIDs groups (P=0.04). There was an increase in the CMT in all cases starting from postoperative first week until third month. CMT showed a statistically significant difference between control group and NSAIDs groups from postoperative first month until third month (P=0.008, 0.027, 0.004). There was no statistically significant difference between nepafenac and ketorolac groups in BCVA and OCT CMT.

CONCLUSION

Prophylactic preoperative and postoperative NSAIDs may have a role in reducing the frequency and severity of CME in diabetic eyes following cataract surgery.

Comparison of macular thickness by optical coherence tomography measurements after uneventful phacoemulsification using ketorolac tromethamine, nepafenac, vs a control group, preoperatively and postoperatively

Purpose

To analyze, using optical coherence tomography, the macular thickness values of patient groups using nonsteroidal anti-inflammatory drug (NSAID) eye drops or artificial tears during uncomplicated cataract surgery.

Methods

A total of 77 eyes from 42 patients were analyzed. The patients were divided into three groups, each using one of the following ophthalmic sterile suspensions: nepafenac (21 eyes), propylene glycol (24 eyes), or ketorolac tromethamine (32 eyes).

Results

The mean macular thicknesses of the nepafenac group, preoperatively as well as at 1, 7, and 45 days postoperatively, were 216.42, 216.61, 222.47, and 218.28, respectively; those of the propylene glycol control group were 218.29, 214.50, 219.37, and 228.45, respectively; and those of the ketorolac tromethamine group were 217.46, 220.71, 225.25, and 228.46, respectively. There were no significant differences between groups at any time, with p-values of 0.971, 0.6742, 0.6711, and 0.327, respectively.

Conclusion

During the study period, no significant differences in macular thickness were observed between the patient groups using two types of NSAIDs or between those groups and the control group that used propylene glycol, indicating that neither drug was superior to the other or the placebo. However, a slight macular thickening, without reduction of visual acuity, was observed in all groups.

Topical nepafenac for prevention of post-cataract surgery macular edema in diabetic patients: patient selection and perspectives

Since its first description, the prevention of pseudophakic cystoid macular edema (PCME) continues to pose challenges for ophthalmologists. Recent evidence suggests that prophylaxis is unnecessary in patients without risk factors. Diabetes mellitus is generally considered as a risk factor for the development of PCME after cataract surgery since it causes breakdown of the blood–retinal barrier. Diabetic retinopathy (DR) increases the risk even further. Therefore, prophylactic nonsteroidal anti-inflammatory drugs (NSAIDs) should be considered in diabetic patients, especially if they have DR. NSAIDs block the cyclooxygenase enzymes responsible for prostaglandin production and reduce the incidence of PCME after cataract surgery. Nepafenac seems superior to other NSAIDs in terms of ocular penetration allowing higher and sustained therapeutic levels in retina and choroid. Topical steroids are less effective and may cause intraocular pressure increase limiting their long-term use. Nepafenac is cost effective, when the burden of PCME prevention is compared with the burden of treatment. Prevention is much cheaper and less harmful than invasive treatments like periocular or intravitreal injections. Overall, both nepafenac 0.1% and nepafenac 0.3% are well tolerated. They should be used carefully in patients with compromised corneas such as those with severe dry eye or penetrating grafts. If otherwise healthy cataract patients have ≥2 risk factors, like PCME in the other eye or posterior capsule rupture during surgery, treatment should be considered. Once-daily nepafenac 0.3% dosing may improve postoperative outcomes through increased patient compliance and may reduce treatment burden further. Every patient should be assessed in terms of risks/benefits of the treatment, in individual basis, before cataract surgery.

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.

The Use of Topical Non-steroidal Anti-inflammatory Drugs for Uveitic Cystoid Macular Edema

The use of topical non-steroidal anti-inflammatory drugs in the management of uveitic cystoid macular edema is controversial. In this letter, we review the literature and report our results from a retrospective case series of 281 patients taking topical nepafenac 0.1% for uveitic cystoid macular edema between 2010 and 2016. Over a 4-month period, there was a modest improvement in best-corrected visual acuity (0.66 ± 3.7 logMAR) and central macular thickness (69.8 ± 132.5 μm). Patients with idiopathic anterior uveitis and HLA-B*27-associated anterior uveitis recovered more vision while taking topical nepafenac 0.1%, than those with other uveitides, however, this was not statistically significant. There is a need for controlled prospective studies to evaluate the efficacy of topical non-steroidal anti-inflammatory drugs in the management of uveitic cystoid macular edema. At present, clinicians have little evidence on which to base practice.

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.

Comparison of Subtenon Triamcinolone Acetonide Injection with Topical Nepafenac for the Treatment of Pseudophakic Cystoid Macular Edema

PURPOSE

To compare the efficacy and safety of subtenon triamcinolone acetonide (TA) injection with topical nepafenac 0.1% for the treatment of pseudophakic cystoid macular edema (CME).

METHODS

In this prospective study, the TA group comprised 24 eyes and the nepafenac group 24 eyes. Best-corrected visual acuity (BCVA), central retinal thickness (CRT), intraocular pressure measurements, and slit-lamp fundoscopy were performed in all subjects at baseline, 1, 2, 3, and 6 months.

RESULTS

Changes in BCVA and CRT over four follow-up visits were statistically significant (p<0.001). The mean CRT decreased from 513.3 to 318.9 μm in the TA group and from 483.7 to 278.0 μm in the nepafenac group. This reduction was statistically significant (p<0.001 for both groups).

CONCLUSIONS

Our visual and OCT results suggest that both treatment modalities are effective with few side-effects. However, nepafenac is more efficacious than subtenon TA in terms of visual gain and its correlation with the reduction in CRT.

Comparison of effect of nepafenac and diclofenac ophthalmic solutions on cornea, tear film, and ocular surface after cataract surgery: the results of a randomized trial

Background

The aim of this study was to compare the effects of nepafenac ophthalmic suspension 0.1% (Nevanac) and diclofenac sodium ophthalmic solution 0.1% (Diclod) on the cornea, tear film, and ocular surface after cataract surgery.

Methods

A total of 60 eyes (60 patients) were selected for this study, with no ocular diseases other than cataract (scheduled for cataract surgery by one surgeon). Patients were randomly enrolled to receive nepafenac or diclofenac in the perioperative period, and cataract surgery was performed using torsional microcoaxial phacoemulsification and aspiration with intraocular lens implantation via a transconjunctival single-plane sclerocorneal incision at the 12 o’clock position. We compared intra- and intergroup differences preoperatively and postoperatively in conjunctival and corneal fluorescein staining scores, tear film breakup times, Schirmer’s tests, the Dry Eye Related Quality of Life Scores, and tear meniscus areas using anterior segment optical coherence tomography.

Results

The diclofenac group had significantly higher conjunctival and corneal fluorescein staining scores at 4 weeks postoperatively compared with the nepafenac group (P<0.001). Within the diclofenac group, significantly higher conjunctival and corneal fluorescein staining scores were noted at 4 weeks postoperatively than those seen preoperatively (P<0.001) and at 1 week postoperatively (P<0.001). No statistically significant differences were found in any other items.

Conclusions

Nepafenac ophthalmic suspension 0.1% is considered safe for the corneal epithelium after cataract surgery.

Prostaglandin E2 Levels of Aqueous and Vitreous Humor in Ketorolac 0.4% and Nepafenac 0.1% Administered Healthy Rabbits

PURPOSE

To compare the lowering effects of ketorolac 0.4% and nepafenac 0.1% on aqueous and vitreous humor prostaglandin E₂ (PGE₂) levels in rabbits.

METHODS

Ketorolac and nepafenac ophthalmic solutions were administered to the right eyes of 24 healthy rabbits after randomized division into two groups. The left eyes of these rabbits were considered as controls for the two groups. On the 4th day of the experiment, the samples were taken from the aqueous and vitreous humors of the rabbits bilaterally, and PGE₂ levels were measured by an enzyme immune assay kit.

RESULTS

Ketorolac and nepafenac achieved a statistically significant decrease (p<0.001, for each) in PGE₂ levels in the aqueous (11.75 ± 6.15 and 14.75 ± 7.60 pg/mL, respectively) and the vitreous humor (6.58 ± 4.62 and 9.83 ± 4.55 pg/mL, respectively).

CONCLUSIONS

Both ketorolac and nepafenac inhibited PGE₂ levels in both the aqueous and vitreous humors of rabbits. Although PGE₂-lowering effects were similar in the aqueous humor, nepafenac seemed to be more potent than ketorolac in the vitreous humor.

One-Day Use of Preoperative Topical Nonsteroidal Anti-Inflammatory Drug Prevents Intraoperative Prostaglandin Level Elevation During Femtosecond Laser-Assisted Cataract Surgery

PURPOSE

To determine if pretreatment with topical nonsteroidal anti-inflammatory drug (NSAID) prior to femtosecond laser-assisted cataract surgery (FLACS) prevents intraoperative prostaglandin level elevation as a potential risk factor of postoperative complications.

PATIENTS AND METHODS

Thirty-six patients with clinically significant cataract and without any concomitant general or ophthalmic disease were enrolled into the three age-matched groups of the study. The mean age of the patients was 62.3 ± 13.1 years. The first group of patients underwent traditional phacoemulsification (Control group), on the second group of patients FLACS was performed, and the third group of patients received topical 0.1% nepafenac pretreatment for 1one day prior to FLACS. Before the phacoemulsification part of the cataract surgery, approximately 110 µL of aqueous humor was collected in all groups. Total prostaglandin concentrations of the collected aqueous humor samples were evaluated by enzyme immunoassay (EIA).

RESULTS

The mean of the total prostaglandin concentrations of the aqueous humor samples was 208.8 ± 140.5 pg/mL in patients in the control group, 1449.1 ± 1019.7 pg/mL in the FLACS group (p > 0.001), and 92.2 ± 51.7 pg/mL in the group pretreated with topical NSAID before the FLACS (p > 0.001 compared to FLACS; p > 0.01 compared to control), respectively.

CONCLUSIONS

FLACS surgery increases intracameral prostaglandin concentration. However, using preoperative 1-day-long nonsteroid anti-inflammatory drops prior to FLACS, this intraoperative increase diminishes. Our study raises the possibility that NSAID pretreatment may be routinely administered before FLACS cataract surgeries to achieve a further decrease in the potential complications of increased total prostaglandin concentration during FLACS surgeries.

Topical ophthalmic NSAIDs: a discussion with focus on nepafenac ophthalmic suspension

The removal of diclofenac sodium ophthalmic solution as a viable pharmaceutical entity in September 1999 from the US market spurred considerable interest in the general safety and effectiveness of topical ophthalmic NSAIDs for treatment of anterior segment inflammation. In late 1999 the use of topical ocular NSAIDs declined in the US as a result of incidents involving corneal melts and toxicity surrounding use of generic diclofenac. However, since the removal of diclofenac sodium ophthalmic solution from the marketplace, ophthalmic NSAIDs have regained use as viable pharmacotherapeutic entities. Moreover, several new ophthalmic NSAID products have recently been introduced for commercial use in the US including the novel chemical entity nepafenac. The purpose of this report is to revisit the use of topical ophthalmic NSAIDs for the treatment of surgically induced anterior segment inflammation with a particular focus on nepafenac. Nepafenac is unique among ophthalmic NSAIDs in that it is a prodrug deaminated to amfenac, a highly effective non-selective cyclooxygenase inhibitor. In the case of topical ophthalmic NSAIDs, practitioners should carefully weigh the cost-benefit of implementing “highly potent” new drug products because perturbations in pharmacodynamic response due to the inherent novelty in terms of chemical designs may outweigh the demonstrated replicative pharmacologic action of all topical ophthalmic NSAIDs.

Topical nepafenac in the treatment of diabetic macular edema

Purpose

To determine the safety and efficacy of topical nepafenac 0.1% in the treatment of diabetic macular edema.

Methods

A consecutive case series was performed of patients treated with nepafenac monotherapy twice daily for diabetic macular edema. Visual acuities (VA) at baseline and final visit were recorded. Foveal thickness, based on optical coherence tomography, was also recorded.

Results

Six eyes of 5 patients were included in this study. Median initial Snellen vision was 20/100 (range, 20/40–20/400). After a mean of 210 days (range, 182–259), median final VA was 20/75 (range, 20/40–20/400). Four eyes gained vision and two eyes maintained vision. Mean pre-treatment vision was 0.78 logMAR and final VA was 0.67 logMAR, for a statistically significant improvement (p < 0.05). Mean initial foveal thickness was 417 microns (range, 286–599). After a mean of 178 days (range, 91–259), mean foveal thickness was 267 microns (range, 158–423), showing a statistically significant improvement (p < 0.05). Each eye had an improvement in foveal thickness.

Conclusion

The results from these 6 eyes suggest that nepafenac 0.1% may have activity against diabetic macular edema and warrants further investigation.

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

Objective:

To evaluate the effectiveness of prophylactic administration of nepafenac 0.1% in maintaining mydriasis and in preventing postoperative macular edema following cataract surgery.

Methods:

This was a prospective, randomized, single-masked comparative study in 60 patients undergoing phacoemulsification cataract surgery. Patients were randomized to either the nepafenac or the control group. Nepafenac was administered 3 times daily 1 day before surgery and continued for 6 weeks. The control group received tobramycin-dexamethasone treatment only. Trans-operative mydriasis was measured before surgery, after nuclear emulsification, following cortex aspiration, and at the conclusion of surgery. Macular optical coherence tomography determined central foveal thickness (FT) and total macular volume (TMV) before surgery and at 2 and 6 weeks after surgery. All patients received tobramycin-dexamethasone for 2 weeks after surgery.

Results:

The difference in mean pupil size, at the end of surgery, between the control group (6.84 ± 0.93 mm) and the nepafenac group (7.91 ± 0.74 mm) was statistically significant (p < 0.001). There were no significant differences in FT values between the two groups at any time point; however, TMV at 2 and at 6 weeks was statistically significantly different (p < 0.001), with higher TMV in the control group.

Conclusion:

Prophylactic use of nepafenac was effective in reducing macular edema after cataract surgery and in maintaining trans-operative mydriasis.

Treatment of cystoid macular edema with the new-generation NSAID nepafenac 0.1%

Purpose:

To describe the use of nepafenac 0.1% for cystoid macular edema (CME).

Methods:

This was a multicenter retrospective review of 22 CME cases (20 patients) treated with nepafenac 0.1% (six with concomitant prednisolone acetate 1%) from December 2005 to April 2008: three acute pseudophakic CME cases, 13 chronic/recalcitrant pseudophakic CME cases, and six cases of uveitic CME. Pre- and post-treatment retinal thickness and visual acuity were reported.

Results:

Following treatment for six weeks to six months, six eyes with uveitic CME showed a mean retinal thickness improvement of 227 ± 168.1 μm; mean best-corrected visual acuity (BCVA) improvement was 0.36 ± 0.20 logMAR. All three cases of acute pseudophakic CME improved after four to 10 weeks of nepafenac, with a mean improvement in retinal thickness of 134 ± 111.0 μm. BCVA improved in two patients (0.16 and 0.22 logMAR) but not in the third due to underlying retinal pigment epithelium changes. Thirteen eyes with chronic/recalcitrant pseudophakic CME demonstrated a mean improvement in retinal thickness of 178 ± 128.7 μm after nepafenac and mean BCVA improvement of 0.33 ± 0.19 logMAR.

Conclusion:

The positive outcomes of these 22 eyes strongly suggest that nepafenac 0.1% is a promising drug for the treatment of CME. Additional study under randomized controlled conditions is warranted.

Analgesic and anti-inflammatory effectiveness of nepafenac 0.1% for cataract surgery

BACKGROUND

To compare nepafenac 0.1% with placebo and ketorolac 0.5% for prevention and treatment of ocular pain and inflammation after cataract surgery.

METHODS

In a multi-center, randomized, placebo- and active-controlled, double-masked clinical trial, 227 patients with cataract were randomized to receive nepafenac 0.1%, ketorolac 0.5%, or placebo TID beginning 1 day pre-operatively and continuing for 21 days postoperatively. At each postoperative visit, cure rates and clinical success rates (</=5 aqueous cells and no flare) were calculated, and investigators evaluated patients' pain. On Day 7, patients judged ocular comfort after study drug instillation.

RESULTS

Nepafenac 0.1% produced significantly more cures compared to placebo at Day 14 (76.3% vs 59.2%, p = 0.0241), more clinical successes from Day 7 onward (p < 0.05), and more pain-free patients from Day 3 onward (p < 0.05). Nepafenac 0.1% was superior to ketorolac 0.5% in terms of clinical success at Day 14 (p = 0.0319) and in percentage of pain-free patients at Day 3 (p = 0.0366). Nepafenac 0.1% also demonstrated less discomfort upon instillation than ketorolac 0.5% (p = 0.0158).

CONCLUSION

The anti-inflammatory efficacy of nepafenac 0.1% is better than that of placebo; it is also more comfortable and at least equal to ketorolac 0.5% in the prevention and treatment of postoperative ocular pain and inflammation.