NSAIDs are valuable surgical tools for cataract surgeons

Patients are demanding more from ocular surgeries, from the basic LASIK procedure to new multifocal IOLs. Because of this, we have now reached a time when it is a more popular standard of care to use NSAIDs both preoperatively and postoperatively to optimize surgical outcomes and make the experience more comfortable for the patient.

The NSAID class recently has expanded with the addition of two new drugs approved last year: bromfenac 0.09% (Xibrom, ISTA Pharmaceuticals) and nepafenac ophthalmic suspension 0.1% (Nevanac; Alcon Laboratories). They join the earlier ones, ketorolac tromethamine 0.5% (Acular, Allergan)-which was one of the first and most widely used medications-and ketorolac tromethamine ophthalmic solution 0.4% (Acular LS, Allergan), which was developed to reduce the incidence of ocular pain and burning/stinging following corneal refractive surgery. This optimized formulation of ketorolac also is used for a range of other conditions including post-surgical inflammation.

During my career, performing approximately 15,000 cataract surgeries, I have seen the benefits of using an NSAID as a surgical tool. The advantages of NSAID use are widely known but bear repeating:

In another study, Dr. Donnenfeld and his colleagues evaluated the importance of pupil dilation in surgical efficiency. They examined the clinical benefit, relative efficacy, and dose-response curve of preoperative NSAIDs as a surgical tool in cataract surgery. The 100 patients were randomly assigned to four groups to receive preoperative ketorolac 0.4% for 3 days, 1 day, 1 hour, or placebo in a double-masked fashion prior to phacoemulsification. The maintenance of pupil size, phacoemulsification time and energy, operative time, corneal clarity, postoperative inflammation, and intraoperative and postoperative discomfort was significantly improved with 3 days of NSAID prophylaxis versus 1 day prophylaxis, which, in turn, was significantly better than instilling the NSAID 1 hour in advance or placebo. In addition, there was a trend toward improved pachometry on postoperative day one and endothelial counts at 3 months in the 3-day pre-treatment group relative to placebo.

In short, the preoperative use of ketorolac 0.4% for 3 days significantly improved surgical efficacy and operative outcomes relative to pre-treatment for 1 day, 1 hour, or placebo. My clinical experience has been consistent with Dr. Donnenfeld's results.

Many surgeons now use NSAIDs or a steroid, but not in combination. Evidence exists, however, suggesting that topical NSAIDs and corticosteroids have the potential for synergistic activity in treating cystoid macular edema (CME). Jeffrey S. Heier, MD, and colleagues found that NSAID treatment alone or combination therapy may be more effective than using a steroid alone. In a randomized, double-masked, prospective trial, 28 patients underwent cataract extraction and developed CME 21 to 90 days after surgery. Patients were randomly assigned to receive ketorolac, prednisolone, or ketorolac and prednisolone combination therapy four times daily. Patients who were treated with combination therapy were more likely to recover 2 or more lines of visual acuity (VA) than patients in the other two groups. Additionally, patients treated with combination therapy or ketorolac monotherapy had a quicker response than patients who received prednisolone monotherapy.

So why do so many surgeons avoid the use of an NSAID in their surgeries? I believe there are four different reasons: safety, cost, convenience, and necessity. A large part of the reason that not all surgeons embrace the use of NSAIDs may rest with the generic diclofenac experience. Several years ago, that drug was associated with corneal melts after routine cataract surgeries, and it was subsequently pulled from the market.