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Anterior Segment Cataract Surgery Topical Bromfenac for Pseudophakic Cystoid Macular Edema – Case Reports G e o r g e V o y a t z i s , 1 A n i l P i t a l i a , 2 C o l i n V i z e 3 a n d M a d h a v a n R a j a n 1,4 1. Addenbrooke’s Hospital, Cambridge; UK; 2. SpaMedica, Manchester, UK; 3. Hull and East Yorkshire Eye Hospital, Hull, UK; 4. Anglia Ruskin University, Cambridge, UK Abstract Cystoid macular edema (CME) is the most common cause of visual loss following uncomplicated cataract surgery and although the condition usually resolves itself within several months, it can result in permanent vision loss in a minority of patients. There is a lack of consensus in diagnostic methods and definition of the condition and as a result, estimates of its incidence vary greatly, ranging from 4 to 41 %. There is also a scarcity of randomised controlled trial data to support the efficacy of ophthalmic agents in the prophylaxis and treatment of CME. However, a growing body of evidence supports the use of topical non-steroidal anti-inflammatory drugs (NSAIDs) both pre-and post-surgery. The importance of the prophylactic use of NSAIDs should be emphasized as many cases of CME are preventable. The combination of corticosteroids and NSAIDs may be more effective than either class of agents alone. The use of bromfenac for the treatment and prevention of CME is growing. Its unique chemical structure makes it highly lipophilic with rapid penetration of ocular tissues; it has sustained anti-inflammatory action and allows less frequent dosing (twice a day as opposed to three or four times a day). This article presents four case studies detailing rapid CME resolution following topical administration of bromfenac. Keywords Bromfenac, cataract surgery, cystoid macular edema, non-steroidal anti-inflammatory drugs, phacoemulsification Disclosure: The authors have no conflicts of interest to declare. Received: 22 September 2012 Accepted: 22 October 2012 Citation: European Ophthalmic Review, 2012;6(4):230–5 Correspondence: Madhavan Rajan, Professor of Ophthalmic and Visual Sciences, Vision and Eye Research Unit, Postgraduate Medical Institute, Anglia Ruskin University, Easting 204, East Road, Cambridge, CB1 1PT, UK. E: madhavan.rajan@addenbrookes.nhs.uk Support: The publication of this article was funded by Bausch & Lomb. The views and opinions expressed are those of the authors and not necessarily those of Bausch & Lomb. Cataract removal is one of the most commonly performed surgeries and in recent years has benefited from advances in technique, lens design and instrumentation. 1 Phacoemulsification surgery via small incisions and implantation of a foldable intraocular lens (IOL) is an effective procedure, and provides good visual outcomes. 2–5 Post-operative complications of cataract surgery however, may occur, including cystoid macular edema (CME) which is the most common cause of visual loss following cataract surgery. 6–8 It is more common in patients with ocular diseases such as uveitis or diabetic retinopathy and after complicated or uncomplicated surgery in patients with otherwise healthy eyes. 9 The development of small incision cataract surgery and phacoemulsification techniques has lowered the incidence of CME, but the total volume of cataract surgeries makes it a common morbidity. Up to 80 % of symptomatic patients show spontaneous improvement in visual function three to 12 months post surgery. In a minority of patients, CME requires treatment and in some cases, it may be refractory to treatment. 10 Prevention of CME through post-operative use of NSAIDs is now standard of care in the US and increasingly practiced in several other countries around the world. In addition, there have been several clinical studies that support the role of NSAIDs in helping prevent CME. 8,10–15 This review considers the use of non-steroidal anti-inflammatory drugs (NSAIDs) in the treatment and prevention of CME with a focus on 230 bromfenac. Four case reports of rapid CME resolution after topical administration of bromfenac are discussed. Definition, Incidence and Cost CME can be detected using either clinical or angiographic methods. Clinical CME is diagnosed using slit-lamp biomicroscopic observation of cystoid abnormalities or angiographic evidence of perifoveal leakage as well as reduced visual acuity (VA). The angiographic CME is diagnosed using fluorescein angiography. The incidence of clinical CME is low, ranging from 0 to 4 %. 16 The incidence of angiographic CME is higher; incidence rates of 19, 15 22 17 and 9 % 18 have been reported. Optical coherence tomography (OCT) is a sensitive technique for high-resolution cross-sectional imaging that directly measures macular thickness and has been increasingly used to assess CME after cataract surgery. 16 Its sensitivity allows the detection of macular thickening in the absence of cysts or any obvious visual impairment. However, it is not performed routinely after cataract surgery. Recent studies have suggested that the peak incidence of CME, as detected by OCT, occurs about four weeks after cataract surgery, whereas most literature reports state that postoperative CME does not begin until six weeks after surgery. 16 Because of the lack of a clear definition for CME and the presence of retinal thickening, a broad range of incidences have been reported. Incidences of CME following phacoemulsification, as identified by OCT, have varied from 4–11 %. 10,19,20 In a study of © TOUCH MEDICAL MEDIA 2012