Routine NSAID use questioned based on multiple factors

Topical nonsteroidal anti-inflammatory drugs (NSAIDs) are often used off-label for multiple purposesin cataract surgery, but such treatment is often being administered with limited supporting evidenceand carries a high cost along with potential risks, said Walter Stark, MD, at Spotlight on Cataracts2007.

The only approved indications for topical NSAIDs in cataract surgery are to treat postoperative painor inflammation. However, these agents are being prescribed off-label outside of those intended usesto potentiate mydriasis as well as to prevent or treat cystoid macular edema (CME).

A few studies have shown topical NSAIDs increase pupil size and decrease constriction. However, gooddata are lacking to show a benefit for CME prevention. When used in eyes with persistent CME, topicalNSAID use has been shown to provide a good response measured by improvement in lines of vision.However, CME recurred within a few months after the medication was stopped in one study.

"At an average wholesale cost of about $79 dollars per bottle and up to $130 retail multiplied by 2.5million cataract operations performed annually, topical NSAID use can add $250 million to the cost ofcare. In addition to the economic consequences, surgeons need also consider use of these agents mightcause complications, including corneal melt," Dr. Stark said.

Dr. Stark told attendees he uses topical NSAIDs preoperatively, administering four doses beginning 1hour prior to surgery when starting the dilating drops. However, in eyes predisposed to CME,prophylactic treatment is initiated 1 to 3 days preoperatively and continued for 2 to 3 weeks aftersurgery.