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Editorial Cataract Restraining Inflammation in Pseudoexfoliation Syndrome Marco Coassin and Luigi Fontana Ophthalmology, Santa Maria Nuova Hospital IRCCS, Reggio Emilia, Italy P atients with pseudoexfoliation syndrome (PEX) experience more intense inflammation after phacoemulsification compared to routine cataracts. The effect of topical nonsteroidal anti-inflammatories (NSAIDs) in eyes with PEX have not been studied to date. Laser flare photometry was used in this study to evaluate subtle amounts of postoperative inflammation. The addition of bromfenac to dexamethasone ophthalmic solution significantly reduced anterior chamber inflammation after cataract surgery in PEX when compared to dexamethasone alone. Postoperative macular thickness at optical coherence tomography (OCT) was also positively affected by the addition of topical bromfenac. Keywords Pseudoexfoliation syndrome, bromfenac ophthalmic solution, cataract surgery Disclosure: Marco Coassin and Luigi Fontana have nothing to disclose in realtion to this article. This article is a short opinion piece and has not been submitted to external peer reviewers. No funding was received in the publication of this article. Authorship: All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship of this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval to the version to be published. Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any noncommercial use, distribution, adaptation, and reproduction provided the original author(s) and source are given appropriate credit. Received: January 13, 2017 Published Online: February 23, 2017 Citation: US Ophthalmic Review, 2017;10(1):19–20 Corresponding Author: Luigi Fontana, Arcispedale S. Maria Nuova IRCCS. Viale Umberto I, 50, 42123 Reggio Emilia,Italy. E: Luigi.Fontana@asmn.re.it Pseudoexfoliation syndrome (PEX) is a common condition that may represent a serious challenge during cataract surgery. 1 Prevalence in the US is up to 14% and is related to aging and low climatic temperature. 2 Also known as ‘Viking disease’, PEX is more common in Northern Europeans: in Sweden, an 87-year-old individual has a 61% chance of having PEX. 3 Pathological features include deposition of a white fibrillar material in the anterior segment of the eye, and this matrix of granular amyloid-like proteins can be found also in other organs. 1 Postoperative inflammation is higher in PEX versus routine cataracts. 1 This is due to a constitutively damaged blood-ocular barrier that leads to increased leakage of serum proteins into the aqueous humor after surgery (flare or Tyndall effect). The fragility of the blood-ocular barrier and intense postoperative inflammation may be responsible for a higher risk of pseudophakic macular edema in PEX eyes. 1 Ophthalmic non-steroidal anti-inflammatory drugs (NSAIDs) are approved for the treatment of inflammation and pain after cataract surgery. 4 NSAIDs have also been shown to prevent formation of postoperative macular edema in some studies. 5 Nevertheless, it is debated if topical NSAIDs may be as effective as steroids in controlling inflammation after cataract surgery and there is lack of consensus about whether they should be given on routine basis in addition to topical steroids. 6 A recent clinical trial demonstrated that bromfenac ophthalmic solution significantly reduced inflammation after cataract surgery when added to dexamethasone eye drops in patients with PEX. 7 Sixty-two patients with cataract and clinical signs of PEX were randomized to dexamethasone 0.1%/tobramycin 0.3% ophthalmic solution alone (Group 1) or with the adjunct of bromfenac ophthalmic solution 0.09% (Group 2). All patients were examined on the day of surgery (baseline) and at postoperative days 1, 3, 7, and 30. Laser flare photometry was used to precisely quantify anterior chamber inflammation and optical coherence tomography (OCT) to measure macular thickness. Flare was 31% lower in Group 2 versus Group 1 at postoperative day 3 (11.92±8.14 versus 17.13±9.03 ph/msec; p=0.025) and 43% lower at day 7 (10.77±6.17 versus 18.72±12.37 ph/msec; p=0.003). There were no significant differences between groups in postoperative visual acuity, symptoms and ocular pain. Mean macular thickness at 1 month post-surgery was increased in Group 1, but not in bromfenac recipients (261.10±34.50 versus 243.38±28.23 microns; p=0.03). The incidence of intraretinal cysts at OCT was higher in Group 1 (n=4) versus the bromfenac group (n=0). Pseudophakic macular edema is due to the breakdown of the blood-retina barrier. 8 Eyes with PEX are at higher risk of developing pseudophakic macular edema. 1 The incidence and the effects of subclinical macular edema after phacoemulsification on vision are probably underestimated. 8 The current study showed increased macular thickness at postoperative week 4 in patients not TOU CH MED ICA L MEDIA 19