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Current Use of Non-steroidal Anti-inflammatory Drugs in the Treatment of Ocular Inflammation Related to Cataract Surgery

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Published Online: May 22nd 2012 European Ophthalmic Review, 2012;6(3):173–7 DOI: http://doi.org/10.17925/EOR.2012.06.03.173
Authors: Eric D Donnenfeld
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Abstract
Article
Article Information
Abstract:
Overview

Ocular inflammation and pain are a common consequence of cataract surgery, and if left untreated, may lead to extensive ocular damage, resulting in impaired vision as well as decreased satisfaction with the procedure. Effective management of ophthalmic inflammation after surgery is therefore vital. Topical ophthalmic non-steroidal anti-inflammatory drugs (NSAIDs) have become a mainstay of management of ocular pain and inflammation as a result of their anti-inflammatory activity, analgesic property and established safety record. Numerous studies have demonstrated the efficacy of topical NSAIDs in post-operative prevention of ocular inflammation, inhibition of intra-operative miosis, reduction of pain associated with cataract surgery and pre-operative use to prevent cystoid macular oedema. Studies have also indicated that NSAIDs and steroids act synergistically when administered together, and that a combination of steroid and NSAID therapy is recommended to achieve successful outcomes. With appropriate administration, NSAIDs are safe and effective therapeutic agents, which rarely result in serious local and systemic responses.

Keywords

Cataract surgery, cystoid macula oedema, miosis, non-steroidal anti-inflammatory drugs

Article:

Cataract surgery is an invasive procedure involving an incision and manipulation of ocular tissue, leading to intraocular inflammation. The latter is characterised by redness, swelling, and/or pain. Inflammation arises from the release of prostaglandins (PGs). Activation of phospholipase A2, following tissue injury during surgery, breaks down cell membrane phospholipids to arachidonic acid. This is then converted to PGs by activation of cyclo-oxygenase (COX) enzymes via the COX-1 and COX-2 pathways. Production of PGs causes local vasodilation and increased vascular permeability resulting in a number of symptoms including hyperaemia, miosis, pain, photophobia and diminished visual acuity secondary to cystoid macular oedema (CMO) – the most common complication of cataract surgery and potentially the most adverse ocular outcome of PG production.1

Two agents are primarily employed for the reduction of intraocular inflammation: non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids. NSAIDs are potent inhibitors of cyclo-oxygenase enzymes and hence of PG synthesis. Together with corticosteroids, they act on the COX-1 and COX-2 pathways. While corticosteroids inhibit phospholipase A2, preventing arachidonic acid release from phospholipids, NSAIDs act downstream and more specifically in the cascade by direct inhibition of COX-1 and COX-2 enzymes (see Figure 1).2 Post-operative ocular inflammation is a complex condition owing to the diverse types of tissues that may be affected, including the conjunctiva, retina, sclera, aqueous and vitreous humour, cornea, iris, ciliary body, choroid and retina.3

Corticosteroids have a long history of use in the management of ocular inflammation but their efficacy is tempered by serious adverse effects including impairment of wound healing, elevation of intraocular pressure (IOP), progression of cataracts, increased susceptibility to microbial infections owing to a suppressed host immune response, delayed corneal epithelial and stromal wound healing, and safety issues associated with long-term use including glaucoma.1

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Article Information:
Disclosure

The author has no conflicts of interest to declare.

Correspondence

Eric Donnenfeld, Ophthalmic Consultants of Long Island, 2000 North Village Avenue, Suite 402, Rockville Centre, NY 11570, US. E: eddoph@aol.com

Support

The publication of this article was funded by Alcon. The views and opinions expressed are those of the author and not necessarily those of Alcon.

Received

2012-06-01T00:00:00

References

  1. Cho H, Wolf KJ, Wolf EJ, Management of ocular inflammation and pain following cataract surgery: focus on bromfenac ophthalmic solution, Clin Ophthalmol, 2009;3:199–210.
  2. Reddy R, Kim SJ, Critical appraisal of ophthalmic ketorolac in treatment of pain and inflammation following cataract surgery, Clin Ophthalmol, 2011;5:751–8.
  3. Colin J, The role of NSAIDs in the management of postoperative ophthalmic inflammation, Drugs, 2007;67:1291–308.
  4. Flach AJ, Topical nonsteroidal antiinflammatory drugs in ophthalmology, Int Ophthalmol Clin, 2002;42:1–11.
  5. Ahuja M, Dhake AS, Sharma SK, et al., Topical ocular delivery of NSAIDs, AAPS J, 2008;10:229–41.
  6. Lane SS, Modi SS, Lehmann RP, et al., Nepafenac ophthalmic suspension 0.1% for the prevention and treatment of ocular inflammation associated with cataract surgery, J Cataract Refract Surg, 2007;33:53–8.
  7. Walters T, Raizman M, Ernest P, et al., In vivo pharmacokinetics and in vitro pharmacodynamics of nepafenac, amfenac, ketorolac, and bromfenac, J Cataract Refract Surg, 2007;33:1539–45.
  8. Gaynes BI, Onyekwuluje A, Topical ophthalmic NSAIDs: a discussion with focus on nepafenac ophthalmic suspension, Clin Ophthalmol, 2008;2:355–68.
  9. Roberts CW, Brennan KM, A comparison of topical diclofenac with prednisolone for postcataract inflammation, Arch Ophthalmol, 1995;113:725–7.
  10. Simone JN, Pendelton RA, Jenkins JE, Comparison of the efficacy and safety of ketorolac tromethamine 0.5% and prednisolone acetate 1% after cataract surgery, J Cataract Refract Surg, 1999;25:699–704.
  11. Hirneiss C, Neubauer AS, Kampik A, et al., Comparison of prednisolone 1%, rimexolone 1% and ketorolac tromethamine 0.5% after cataract extraction: a prospective, randomized, double-masked study, Graefes Arch Clin Exp Ophthalmol, 2005;243:768–73.
  12. Holzer MP, Solomon KD, Sandoval HP, et al., Comparison of ketorolac tromethamine 0.5% and loteprednol etabonate 0.5% for inflammation after phacoemulsification: prospective randomized double-masked study, J Cataract Refract Surg, 2002;28:93–9.
  13. Solomon KD, Vroman DT, Barker D, et al., Comparison of ketorolac tromethamine 0.5% and rimexolone 1% to control inflammation after cataract extraction. Prospective randomized double-masked study, J Cataract Refract Surg, 2001;27:1232–7.
  14. Henderson BA, Gayton JL, Chandler SP, et al., Safety and efficacy of bromfenac ophthalmic solution (Bromday) dosed once daily for postoperative ocular inflammation and pain, Ophthalmology, 2011;118:2120–7.
  15. Solomon KD, Turkalj JW, Whiteside SB, et al., Topical 0.5% ketorolac vs 0.03% flurbiprofen for inhibition of miosis during cataract surgery, Arch Ophthalmol, 1997;115:1119–22.
  16. Cervantes-Coste G, Sanchez-Castro YG, Orozco-Carroll M, et al., Inhibition of surgically induced miosis and prevention of postoperative macular edema with nepafenac, Clin Ophthalmol, 2009;3:219–26.
  17. Srinivasan R, Madhavaranga MS, Topical ketorolac tromethamine 0.5% versus diclofenac sodium 0.1% to inhibit miosis during cataract surgery, J Cataract Refract Surg, 2002;28:517–20.
  18. Snyder RW, Siekert RW, Schwiegerling J, et al., Acular as a single agent for use as an antimiotic and anti-inflammatory in cataract surgery, J Cataract Refract Surg, 2000;26:1225–7.
  19. O'Brien TP, Emerging guidelines for use of NSAID therapy to optimize cataract surgery patient care, Curr Med Res Opin, 2005;21:1131–7.
  20. Flach AJ, The incidence, pathogenesis and treatment of cystoid macular edema following cataract surgery, Trans Am Ophthalmol Soc, 1998;96:557–634.
  21. Ursell PG, Spalton DJ, Whitcup SM, et al., Cystoid macular edema after phacoemulsification: relationship to bloodaqueous barrier damage and visual acuity, J Cataract Refract Surg, 1999;25:1492–7.
  22. Ray S, D'Amico DJ, Pseudophakic cystoid macular edema, Semin Ophthalmol, 2002;17:167–80.
  23. Miyake K, Masuda K, Shirato S, et al., Comparison of diclofenac and fluorometholone in preventing cystoid macular edema after small incision cataract surgery: a multicentered prospective trial, Jpn J Ophthalmol, 2000;44:58–67.
  24. Henderson BA, Kim JY, Ament CS, et al., Clinical pseudophakic cystoid macular edema. Risk factors for development and duration after treatment, J Cataract Refract Surg, 2007;33:1550–8.
  25. Donnenfeld ED, Perry HD, Wittpenn JR, et al., Preoperative ketorolac tromethamine 0.4% in phacoemulsification outcomes: pharmacokinetic-response curve, J Cataract Refract Surg, 2006;32:1474–82.
  26. Endo N, Kato S, Haruyama K, et al., Efficacy of bromfenac sodium ophthalmic solution in preventing cystoid macular oedema after cataract surgery in patients with diabetes, Acta Ophthalmol, 2010;88:896–900.
  27. Miyake K, Ota I, Miyake G, et al., Nepafenac 0.1% versus fluorometholone 0.1% for preventing cystoid macular edema after cataract surgery, J Cataract Refract Surg, 2011;37:1581–8.
  28. Price MO, Price FW, Efficacy of topical ketorolac tromethamine 0.4% for control of pain or discomfort associated with cataract surgery, Curr Med Res Opin, 2004;20:2015–9.
  29. Nardi M, Lobo C, Bereczki A, et al., Analgesic and antiinflammatory effectiveness of nepafenac 0.1% for cataract surgery, Clin Ophthalmol, 2007;1:527–33.
  30. Aragona P, Tripodi G, Spinella R, et al., The effects of the topical administration of non-steroidal anti-inflammatory drugs on corneal epithelium and corneal sensitivity in normal subjects, Eye (Lond), 2000;14( Pt 2):206–10.
  31. Flach AJ, Topical nonsteroidal antiinflammatory drugs for ophthalmic use, Int Ophthalmol Clin, 1996;36:77–83.
  32. Flach AJ, Corneal melts associated with topically applied nonsteroidal anti-inflammatory drugs, Trans Am Ophthalmol Soc, 2001;99:205–10.
  33. Wittpenn JR, Silverstein S, Heier J, et al., A randomized, masked comparison of topical ketorolac 0.4% plus steroid vs steroid alone in low-risk cataract surgery patients, Am J Ophthalmol, 2008;146:554–60.
  34. Heier JS, Topping TM, Baumann W, et al., Ketorolac versus prednisolone versus combination therapy in the treatment of acute pseudophakic cystoid macular edema, Ophthalmology, 2000;107:2034-8.
  35. Gaynes BI, Fiscella R, Topical nonsteroidal anti-inflammatory drugs for ophthalmic use: a safety review, Drug Saf, 2002;25:233–50.

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