Anti-infective, NSAID dosing varies by surgeon, procedure

November 1, 2004

How nonsteroidal anti-inflammatory agents (NSAIDs) and anti-infective drugs are used during cataract and refractive procedures varies depending with the procedure and the physician performing it. A few high-volume refractive surgeons explained their regimens and why use of the drugs differs.

NSAIDs are mandatory for all cataract surgeries in his practice, according to Y. Ralph Chu, MD. One hour before surgery, patients receive a dose every 10 minutes. Intraoperatively, administration of an NSAID is also important because it prevents pupillary constric- tion, which Dr. Chu said is supported by several studies. Postoperatively, the drug controls inflammation and prevents the development of cystoid macular edema. This effect is augmented, he noted, when the NSAID therapy is combined with a topical steroid.

Administration of an NSAID, such as ketorolac tromethamine, starts 2 days before the procedure in Dr. Katsev's practice at a frequency of four times a day; this regimen then continues for 4 weeks postoperatively to decrease the risk of cystoid macula edema.

Tueng Shen, MD, PhD, offers a different approach for cataract patients.

"For those who are at high risk, such as patients who have diabetes, I use ketorolac tromethamine for 1 week four times a day before surgery and then continue it at the same dosage postoperatively. Those patients will benefit the most from an NSAID. All patients receive an NSAID 1 hour prior to cataract surgery (flurbiprofen sodium) every 15 minutes. I do not use ketorolac tromethamine after cataract surgery on a routine healthy patient. Patients receive prednisolone (Pred Forte, Allergan) four times a day after surgery. If there is capsular compromise during surgery, I then use ketorolac tromethamine postoperatively," said Dr. Shen, direc- tor, Refractive Surgery Center, University of Washington, Seattle.

When performing PRK, Dr. Katsev prescribes an NSAID for use four times daily (ketorolac tromethamine). With LASIK, because there is not a great deal of patient discomfort associated with the procedure, he prescribes preservative-free ketorolac tromethamine on an as-needed basis.

When performing LASEK and PRK, Dr. Shen uses ketorolac tromethamine intraoperatively and four times a day for the first 3 to 4 days after surgery to attenuate pain and to control inflammation. In addition to ketorolac tromethamine, all patients receive prednisolone four times a day for 1 week. For LASIK, she does not use ketorolac tromethamine, because of the low degree of patient discomfort, but the anti-inflammatory prednisolone.

Dr. Chu uses one drop of ketorolac tromethamine before refractive surgery both to augment the effects of anesthesia and decrease patient discomfort. He and his colleagues also administer one drop of ketorolac tromethamine after the procedure to help alleviate the initial feelings of scratchiness or discomfort that may be present after LASIK.