A hot topic in cataract surgery is alternative ways to administer perioperative medications with the goal of lowering the incidence of cystoid macular edema (CME). One way to achieve that goal would be the combination of non-steroidal anti-inflammatory drugs (NSAIDs) and transzonular steroids.
Zephyrhills, FL-A hot topic in cataract surgery is alternative ways to administer perioperative medications with the goal of lowering the incidence of cystoid macular edema (CME). One way to achieve that goal would be the combination of non-steroidal anti-inflammatory drugs (NSAIDs) and transzonular steroids.
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“When considering steroids versus non-steroidals versus drops, many of us were trained to use antibiotic steroid and non-steroidal drops before surgery,” Ahad Mahootchi, MD, said. “However, there has been a trend to start using some of these medications in the eye.”
Based on this principle, Dr. Mahootchi had the idea to compare the incidence of CME postoperatively in cases in which steroid or NSAID drops were added to transzonular triamcinolone, moxifloxacin, and vancomycin. “I wanted to see if giving the steroid first, and then the NSAID, made any difference in the incidence of CME.”
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To determine the benefits of this approach, Dr. Mahootchi, in private practice at Zephyrhills, FL, conducted a single-surgeon comparative case series that include 415 patients in each of three groups:
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• Traditional approach of steroidal and NSAID antibiotic drops administered postoperatively and no transzonular medications;
• Transzonular medications with steroid drops (prednisolone acetate) administered postoperatively;
• Transzonular medications with NSAID drops (generic ketorolac) administered postoperatively.
Patients were followed for 90 days, during which period patients with any finding of CME on examination, any visual complaint, and vision below 20/30 were suspected of having CME and underwent optical coherence tomography (OCT).
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Dr. Mahootchi reported that in Group 1, the incidence of CME was 1.9%.
“In Group 2, with an incidence of CME of 1.9%, adding the steroid did not increase the incidence of CME, but adding an intravitreal steroid also did not decrease it,” Dr. Mahootchi said. “This confirmed what other investigators have reported previously. Finally, in Group 3, the incidence of CME was 0%, which was unexpected and stunning.”
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One consideration is that perhaps the Group 3 regimen delays the onset of CME. Therefore, it is unknown what might have happened later than 90 days postoperatively, Dr. Mahootchi noted.
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“It was really not valid to compare the results after 90 days with everything that I have done previously,” Dr. Mahootchi explained. “But, we kept counting and concluded that if using a transzonular steroid and an antibiotic at the time of surgery, it is probably beneficial to use an NSAID drop postoperatively to reduce the incidence of CME. However, when we looked at 566 patients who were given only an NSAID in the postoperative period, the incidence of CME increased to only 0.5%. Adding NSAID drops to a transzonular steroid improves CME outcomes overall.”
Ahad Mahootchi, MD
This article was adapted from Dr. Mahootchi’s presentation at the 2015 meeting of the American Academy of Ophthalmology. He is a speaker for Imprimis Pharmaceuticals.