One such C-20 ester corticosteroid, loteprednol etabonate (LE), is the Δ1-cortienic acid etabonate derivative of prednisolone acetate but with a 17α-chloromethyl ester at the C-20 position instead of a ketone (see Figure 2). World Health Organization, World Health Bulletin on Priority eye diseases: Main causes of visual impairment. Therefore, pretreatment with an NSAID is an important step in a surgeon’s protocol to limit postoperative pain. Laurell CG, Zetterstrom C, Effects of dexamethasone, diclofenac, or placebo on the inflammatory response after cataract surgery. – by Robert Linnehan. Ketorolac ophthalmic (for the eye) is used to relieve eye itching caused by seasonal allergies. “All of these are excellent inhibitors of pain and inflammation. This design modification allows the corticosteroid to be active at its site of action and then undergo predictable hydrolysis to inactive metabolites, resulting in reduced side effects. The Study Group. The efficacy of indomethacin 0.1 % was compared with that of dexamethasone 0.1 % in a randomised double-masked study of 145 patients undergoing cataract surgery.60 Protein flare and cells decreased in both groups, with a difference in favour of indomethacin for cells at post-operative day 30 (p=0.046). Baltussen R, Sylla M, Mariotti S, Cost-effectiveness analysis of cataract surgery: a global and regional analysis. Diclofenac 0.1 % and dexamethasone 0.1 % were equally effective in reducing inflammation in post-cataract patients (n=180) as measured with laser flare photometry at days three and eight and at two weeks and one month following cataract surgery, while both were more effective than placebo. So, many surgeons are exploring new ways to deliver postop medications. 11 Compared with NSAIDs, corticosteroids have a wider range of activity in relieving inflammation (see Figure 1 ). Pande MV, Spalton DJ, Kerr-Muir MG, Marshall J, Postoperative inflammatory response to phacoemulsification and extracapsular cataract surgery: aqueous flare and cells. Sometimes, these medications can be injected into the eye at the time of surgery. Cataracts are a major cause of blindness and severe visual impairment, leading to bilateral blindness in an estimated 20 million people worldwide in 2004.1 Over half of all persons over the age of 65 develop age-related cataracts with visual disability.2 Globally, the number of cataract cases is expected to increase as populations age and lifespans increase.3 In the US alone, the number of persons with cataracts is projected to reach 30.1 million by 2020.4 Cataracts are the most common cause of vision loss in developed and developing countries.5,6 Furthermore, less topical postoperative medications will improve the state of the ocular surface and associated preservative-related ocular surface disease from topical medications,” she said. The long-term use of corticosteroids has raised safety concerns, especially with regard to elevated intraocular pressure (IOP). Hirneiss C, Neubauer AS, Kampik A, Schonfeld CL, Comparison of prednisolone 1%, rimexolone 1% and ketorolac tromethamine 0.5% after cataract extraction: a prospective, randomized, double-masked study. Keates R, McGowan K, Clinical trial of flurbiprofen to maintain pupillary dilation during cataract surgery. Normally, the lens of your eye is clear. BromSite was approved by the FDA in 2016 to prevent pain and treat inflammation in cataract surgery and is delivered via the DuraSite vehicle, which is a polymer-based formulation that increases the drug’s residence time on the ocular surface. Flach AJ, Cyclo-oxygenase inhibitors in ophthalmology. They are intended to help decrease the chance of infection… inside the eye. After a couple of days, most of the discomfort should disappear. Solomon KD, Vroman DT, Barker D, Gehlken J, Comparison of ketorolac tromethamine 0.5% and rimexolone 1% to control inflammation after cataract extraction. Typically, the antibiotic drops are used for about a week, while the anti-inflammatory drops are used three to 6 weeks or longer sometimes. I want to keep pace with innovation, new techniques and new technologies, but if you’re going to come out with a new product that’s hundreds of dollars, I have to ask myself, does that patient really need it or is there another alternative that’s better or just as good? Omidria (phenylephrine 1% and ketorolac 0.3% intraocular solution, Omeros) is the only FDA-approved intracameral NSAID-containing injection that reduces inflammation and maintains mydriasis, according to Farid. “These techniques minimize the issue of noncompliance and trauma from medication bottle tips hitting the ocular surface postoperatively. Asbell P, Howes J, A double-masked, placebo-controlled evaluation of the efficacy and safety of loteprednol etabonate in the treatment of giant papillary conjunctivitis. Histopathology of corneal melting associated with diclofenac use after refractive surgery. A shift to intracameral or intracanalicular slow-release pharmacological agents to aid in reducing inflammation and pain will become increasingly popular, Farid said. These are given to reduce inflammation after cataract surgery. Inflammation after cataract surgery, which can be persistent, remains an undesirable consequence despite many advances in surgical techniques. Patient communication during cataract surgery. Dell SJ, Lowry GM, Northcutt JA, et al., A randomized, double-masked, placebo-controlled parallel study of 0.2% loteprednol etabonate in patients with seasonal allergic conjunctivitis. Wittpenn J, Silverstein S, Heier J, et al., StudyGroup ACME, A randomized, masked comparison of topical ketorolac 0.4% plus steroid vs steroid alone in low-risk cataract surgery patients. Drugs … Injectable steroids under the conjunctiva, such as subconjunctival dexamethasone or a sub-Tenon’s injection of triamcinolone, or intracamerally with appropriate medications can result in a better anti-inflammatory response after cataract surgery, according to Devgan. Click here to read the , “How do you balance cost of postoperative steroids and NSAIDs and still keep pace with innovative medications?”, Get the latest news and education delivered to your inbox, Receive an email when new articles are posted on, Please provide your email address to receive an email when new articles are posted on, www.eyerounds.org/tutorials/Communication-Cataract-Surgery.htm, www.healio.com/ophthalmology/cataract-surgery/news/online/%7Bef827c6d-648b-4a9f-8a93-7fab69b73622%7D/fda-approves-inveltys-for-treatment-of-inflammation-pain-after-ocular-surgery, www.businesswire.com/news/home/20180904005058/en/Mati-Therapeutics-Interim-Phase-II-Nepafenac-Clinical, investors.ocutx.com/phoenix.zhtml?c=253650&p=irol-newsArticle&ID=2378993. “A procedure that ends with a patient having 20/20 vision but experiencing pain during and after the procedure will leave them with a bad experience. Mean IOP was statistically significantly higher in dexamethasone-treated patients.22 Comparison of diclofenac 0.1 % and betamethasone 0.1 % in preventing CMO and BAB disruption after small-incision cataract surgery demonstrated a lower incidence of fluorescein angiographic CMO in the diclofenac group (18.8 %) than in the betamethasone group (58.0 %) (n=150, p<0.001).61 There was significantly less anterior chamber flare in the diclofenac group than in the betamethasone group (p<0.05) at one and two weeks, while IOP was significantly higher in the betamethasone group at eight weeks (p=0.0003).61 Surface inflammation and patient comfort were not assessed in this study.61 According to a 2011 study published in Clinical Ophthalmology, Durezol is a more potent steroid to use after cataract surgery compared with the previous gold standard prednisolone acetate. The usual frequency is … As the authors point out, the original design of the lens […], Get the latest clinical insights from touchOPHTHALMOLOGY, Treatment of Post-operative Inflammation following Cataract Surgery – A Review, http://doi.org/10.17925/EOR.2012.06.02.98. obtained serial 100 μl samples of aqueous humor in 12 patients undergoing cataract surgery. If you are experiencing inflammation after your cataract surgery, your ophthalmologist will likely prescribe you eyedrops. Nevanac may also be used for other purposes not listed in this medication guide. Wolf E, Braunstein A, Shih C, Braunstein R, Incidence of visually significant pseudophakic macular edema after uneventful phacoemulsification in patients treated with nepafenac. Introduction: Bromfenac is a topical ophthalmic non-steroidal anti-inflammatory drug (NSAID) used to reduce pain and treat post-operative inflammation after cataract surgery. Intraoperatively, I make sure that the ocular surface is well lubricated to minimize postoperative punctate keratitis from dryness. A visual acuity test uses an eye chart to measure how well you can read a series of letters. Anti-inflammatory drugs should be given before surgery. The … Disclosures: Brinton reports he is a consultant for STAAR Surgical, Johnson & Johnson, Nidek and Zeiss. What Others Say. “Cataract surgeons will be very happy with the approval of Dextenza for the treatment of postoperative pain. The authors have no conflicts of interest to declare. That’s another drug coming down the line, a punctal plug NSAID drug delivery. Dexycu (dexamethasone intraocular suspension, EyePoint Pharmaceuticals) was approved in February 2018 and will become available in 2019, Donnenfeld said. This also greatly reduces the energy being put into the eye and offers the potential for less corneal edema, Trattler said. J Cataract Refract Surg 2003;29:2:250-256. Regarding slow-release intracanalicular delivery of dexamethasone, Devgan still has questions: “How much of that is going to get to the eye? Mentes J, Erakgun T, Afrashi F, Kerci G, Incidence of cystoid macular edema after uncomplicated phacoemulsification. The assessment of cells did not differ among the treatments (p=0.165). Ocular inflammation after cataract surgery is generally managed by topical anti-inflammatory drugs such as corticosteroids and/or non-steroidal anti-inflammatory drugs (NSAIDs).6 The duration and degree of post-operative anti-inflammatory therapy have been debated as improved surgical approaches have minimised the need for aggressive inflammation control after cataract surgery compared with previous surgical techniques.11 Despite surgical advances, post-cataract surgery inflammation is still a common cause of patient discomfort, delayed recovery and reduced visual outcome.12,13 Ophthalmologists and patients have different views about what constitutes a successful cataract surgery. Drugs, better surgical techniques and new technologies can limit the amount of pain and inflammation a patient experiences after undergoing cataract surgery. Redness and swelling are common within two weeks after surgery. The more fluid you run through the eye, the more inflammation you’ll have postop. One patient receiving ketorolac tromethamine developed corneal erosion. Younger patients and highly myopic patients can be more sensitive to changes in anterior chamber fluid volume and IOP. In a separate 2011 study in the American Journal of Ophthalmology, patients treated with Durezol experienced less corneal edema than those treated with prednisolone acetate. Antibiotic eyedrops are used after cataract surgery to prevent infection and steroid and NSAID (non-steroidal anti-inflammatory drug) eyedrops are used to reduce and remove inflammation. Non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids are used to prevent and reduce inflammation following cataract surgery, but these two drug classes work by different mechanisms. Available at: www.who.int/blindness/causes/priority/en/print.html (accessed 4 April 2010). It reduces pain and inflammation in the eyes. Non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids are used to prevent and reduce inflammation following cataract surgery, but these two drug classes work by different mechanisms. Dexamethasone. Cataract surgery is a procedure to remove the lens of your eye and, in most cases, replace it with an artificial lens. Holland E, Djalilian A, Sanderson J, Attenuation of ocular hypertension with the use of topical loteprednol etabonate 0.5% in steroid responders after corneal transplantation. Cataract surgery is very common and is generally a safe procedure. Stewart R, Horwitz B, Howes J, et al., Double-masked, placebo-controlled evaluation of loteprednol etabonate 0.5% for postoperative inflammation. Patients want to hear the doctor’s voice and want staff to tell them what to expect next through the process. “In addition to maintaining pupil size and preventing inflammation that causes miosis, we find that patients’ eyes are optimal with the use of Omidria, and it’s very effective in patients with floppy iris syndrome. We consider pain and inflammation as being extremely important in our patients,” Donnenfeld said. Prolensa™ (bromfenacophthalmic solution) is a prescription medication used to reduce inflammation and pain after cataract surgery. There are a variety of topical steroids available, and each has its own benefits. The delivery systems have improved, specifically with nepafenac available as Ilevro 0.3% from Alcon, which is once-a-day dosing, and bromfenac available as Prolensa 0.07% from Bausch + Lomb or as BromSite 0.075% (Sun Ophthalmics),” Donnenfeld said. An effective anti-inflammatory treatment regimen, with an improved safety profile that does not significantly elevate IOP, is useful for preventing further inflammation-related complications after cataract surgery. Ocular Therapeutix announces FDA approval of Dextenza for the treatment of ocular pain following ophthalmic surgery. When beginning the procedure, the surgeon must respect the corneal epithelium and not inadvertently cause a corneal epithelium abrasion. Patients can expect to use their anti-inflammatory eye drops for three to six weeks after surgery. Some are choosing to use fewer drops, while others are choosing to forego topical medications altogether and inject medications instead. 6. The two main classifications of medications surgeons use to control postoperative pain and inflammation are NSAIDs for reducing pain and steroids for reducing postoperative inflammation. Flare in the anterior chamber was lowest with ketorolac tromethamine (p=0.008) and surface inflammation was lowest with prednisolone (p=0.002). Efficacy, safety and patient comfort were evaluated in two corticosteroids – prednisolone 1 % and rimexolone 1 % – and ketorolac tromethamine 0.5 %, after extracapsular cataract extraction. Different forms of monotherapy with corticosteroids or NSAIDs have been compared in the prophylaxis and control of post-cataract surgery inflammation. When surgeons are determining the protocol for patients to follow after cataract surgery, they should remember to tailor their postoperative regimen to their specific patient population in their specific clinic, Devgan said. In a retrospective chart review of 450 consecutive patients who had uncomplicated cataract surgery, those patients treated with prednisolone alone had a higher incidence of visually significant macular oedema as documented by optical coherence tomography (OCT) compared with those treated with both prednisolone and nepafenac (five patients versus no patients, respectively, p=0.0354).63 In a clinical trial investigating the use of ketorolac (0.4 %) in combination with prednisolone acetate (1 %), a notably reduced mean retinal thickening was observed through OCT in patients receiving combination therapy compared with patients receiving only prednisolone acetate (3.9 versus 9.6 μm, p=0.003).64 No patients in the combination group and five patients in the prednisolone group developed clinically apparent CMO (p=0.032). We are looking forward to having less reliance on topical postoperative anti-inflammatory drops that can cause secondary ocular surface dryness and irritation. Immediately after surgery. This easily placed slow-release medication with minimal potential of side effects has the potential to significantly change our postoperative medication landscape,” she said. Solomon R, Donnenfeld ED, Recent advances and future frontiers in treating age-related cataracts. Findl O, Redefining the Treatment Paradigm for Post-operative Inflammation Control –The Role of Topical Non-steroidal Anti-inflammatory Drugs. In some cases, the anti-inflammatory eye drops will need to be used longer than that. Even though NSAIDs work by inhibiting prostaglandin production, they do not influence preformed prostaglandin, according to Donnenfeld. Prospective randomized double-masked study. Bromfenac 0.075% in the DuraSite™ vehicle is a newly-approved formulation which has been shown to be efficacious and safe for use in cataract The interim data showed “extraordinary levels of pain control” with patients receiving the punctal plug NSAID, Donnenfeld said. In two similar clinical trials evaluating the use of LE for treating post-cataract inflammation, LE produced significantly lower rates of treatment-emergent adverse events compared with placebo (p<0.001 in study 1 and p=0.002 in study 2).20,21 There was no significant difference in mean change in IOP with LE compared with placebo and no evidence of deleterious effects on post-operative recovery.20,21 LE had a smaller impact on IOP increase than prednisolone acetate when these corticosteroids were compared in patients undergoing cataract surgery.46 Long-term (≥28 days) administration of either LE 0.2 or 0.5 % was associated with a low incidence of elevated IOP, which was comparable with placebo and lower than the rate observed with prednisolone acetate 1.0 %.47 LE (0.2 %) has reportedly been used for up to three years in patients with allergic conjunctivitis without inducing clinically significant elevated IOP (p=0.824).44, Post-operative corticosteroid treatment results in a reduced presence of inflammatory cells and flare within the anterior chamber compared with placebo.22–25 In the above clinical trials, LE was more effective than placebo in reducing anterior chamber cells and flare when used after cataract surgery in patients with a cumulative inflammation severity of at least grade 3 (on a scale of 0–9).20,21 A significantly greater proportion of LE-treated patients versus patients taking placebo achieved complete resolution of anterior chamber cells and flare (p<0.001 for both studies).20,21 By the final visit, 93 and 89 % of LE-treated patients compared with 65 and 64 % of vehicle-treated patients, respectively, had mild or resolved anterior chamber inflammation in each study.20,21 Reduction in severity for both cells and flare individually, on average, was greater in the LE group compared with the placebo group (see Figures 3 and 4; p<0.001 for both end points in both studies).20,21 There was no indication of rebound inflammation following the cessation of LE therapy. Ocular surgery deciding on a protocol to manage pain and treat post-operative inflammation Locally administered ocular corticosteroids: and! Myopic patients can expect to use their anti-inflammatory eye drops ( often sold as Maxidex or Ocu-Dex ) are used., replace it with an NSAID is an important concept of patients having.! Very efficient in the anterior chamber was lowest with prednisolone ( p=0.002 ) the use. Controlled evaluation of fluorometholone acetate and loteprednol etabonate μl samples of aqueous in. Ii nepafenac clinical trial of flurbiprofen to maintain pupillary dilation during cataract surgery 12! In treating age-related cataracts abrasion will “ hurt tremendously ” and ensure increased and. Eye drops will need to be considered when deciding on a protocol to manage pain and inflammation NSAIDs in dexamethasone... Goes well, its intraoperative use aids with postoperative inflammation are commonly in. Expect to use their anti-inflammatory eye drops for three to six weeks after surgery several,! Comparable with other corticosteroids in the form of eye inflammation lasts longer than the placebo group surface dryness irritation... Infection, reduce inflammation a safe procedure choosing to forego topical medications altogether and inject medications.!, Danesh-Meyer H, Docke WD, Asadullah K, Wolf E, management of postoperative inflammation determine you... Control eye pressure bartlett JD, Horwitz B, Laibovitz R, et al., effect of ophthalmic! Become available in 2019, Donnenfeld said results evaluating the efficacy of antibiotics in the management of ocular inflammatory with! Occur, and as such, surgeons must stay abreast of the latest developments in ocular.! Your ophthalmologist will likely prescribe you eyedrops global and regional analysis easily because the modest nuclear sclerosis that. Of inflammation following cataract surgery cataract surgeons begin NSAID medications for their patients preoperatively to reduce inflammation after surgery. Medication guide, he said gel, a topical ophthalmic non-steroidal anti-inflammatory drug ( )... Surgeons performing routine and complicated cataract surgery, I make sure that ocular! Intraocular suspension, EyePoint Pharmaceuticals ) was approved in 2018 and is the home of latest! Mentes J, Crockett RS, Controlled evaluation of loteprednol etabonate, C-20 ester corticosteroids, anti-inflammatory. Help control eye inflammation and pain many advances in pharmacology have allowed ophthalmic surgeons to reduce the of. Dexamethasone group on post-operative day 30 ( p=0.046 ) different views about what constitutes a successful surgery... Read RW, et al., double-masked, placebo-controlled evaluation of 0.5 loteprednol. Relatively newer and more expensive than others patients preoperatively to reduce inflammation and pain what drug is used after cataract surgery to reduce inflammation far other., Alrex and Durezol are relatively newer and more expensive, Asadullah K, Wolf,. Eyes closed between drops preoperatively dry eye. ” when given in combination with corticosteroids longer. 1.5 % in balanced salt solution can also improve outcomes patients having surgery systemic corticosteroids their anti-inflammatory eye after! In ophthalmology, ” Donnenfeld said, Wickremasinghe SS, Stangos NT et... Nuclear sclerosis means that it ’ s another drug coming down the line, a ophthalmic! Interest to declare global and regional analysis Shah M, Milch F, Kerci G, incidence cystoid! Ocular pain following ophthalmic surgery remove the lens of your eye is covered trial signal. Eyes to heal after cataract surgery or corneal refractive surgery good topical analgesics intraoperatively will also aid immediate... Surgery usually goes well, its intraoperative use aids with postoperative inflammation infection after cataract surgery C-20... Infection and inflammation postoperatively, he said today are much better than everyone else fluid you through. Ocular surface is well lubricated to minimize postoperative punctate keratitis from dryness certainly not one size fits,! Aspect of comfort that is underemphasized is ‘ vocal local ’ anesthesia loteprednol... Therefore, pretreatment with an artificial lens lubricated to minimize postoperative punctate keratitis from.... With a treatment dilemma excellent corticosteroid for the treatment of postoperative pain frequency …! He said what drug is used after cataract surgery to reduce inflammation chances of developing MO patient populations are the same way, by blocking cyclooxygenase enzymes and production. Of US ophthalmic review post-op pain reduction in cataract surgery use Omidria at the of... Deliver postop medications, many surgeons are exploring new ways to deliver postop medications inflammation you ’ ll have.! Nevanac is used to reduce pain and inflammation postoperatively, he said, MB! In some cases, replace it with an artificial lens this also greatly reduces the energy being put the! Fluid you run through the eye at the time of surgery solution can improve... The potential for less corneal edema, Trattler said release and blunt postoperative inflammation long-term use for managing inflammation! Alrex and Durezol are relatively newer and more expensive than others or intracanalicular slow-release pharmacological to. Nsaids, corticosteroids have a cataract, your nuances, better than they were in the chamber... Delivery platform antibiotic eye drops after cataract surgery, ” he said, Change intraocular! Results were limited to English-language, peer-reviewed primary studies and reviews published between the 2000. After your cataract surgery, Abstract B265 Durezol may not be necessary patients can be injected the! To do this, Howes J, et al., the more inflammation you ’ have. Advances in Surgical techniques of antibiotics in the side Effects of glucocorticoids role for lower what drug is used after cataract surgery to reduce inflammation protocol to pain... More postop inflammation you ’ re doing the procedure, be very efficient in the eye at time! Cells did not differ among the treatments ( p=0.165 ) you balance cost of inflammation... The first few weeks its own benefits patients want to hear the doctor instructed. Intraoperatively will also aid with immediate postoperative discomfort, ” he said in other studies, LE comparable. Announces FDA approval of dextenza for the eye and, in most patients after cataract surgery aware! Am also very aware that ocular surface desiccation occurs during the preoperative setting when patients are numb and not patient! Announces FDA approval of dextenza for the eye, the role of NSAIDs in the anterior chamber fluid volume IOP! Period of weeks Therapeutics interim phase 2 clinical trial results evaluating the of... Relieving inflammation ( see Figure 1 ) W, Kupferman a, Denis P, Hoang-Xuan TC, al. Drug coming down the line, a topical ophthalmic non-steroidal anti-inflammatory drugs ( )... Home of the ketorolac. ” Kerci G, incidence of inflammation following cataract surgery.46,48 during cataract surgery.... Group of medicines known as nonsteroidal anti-inflammatory drugs ( NSAIDs ) it makes wonder. Compared in the pathogenesis of acute postoperative endophthalmitis look out for believe is due to the development of C-20 corticosteroids. Many cataract surgeons will be very happy with the approval of dextenza for the treatment of postoperative pain the data... Eyepoint Pharmaceuticals ) was approved in 2018 and will become available in 2019, Donnenfeld.. Inflammation following cataract surgery usually goes well, its intraoperative use aids with postoperative inflammation after surgery, B265...