JCRS article reviews uses of NSAIDs Vol 19
Literature review examines important considerations of nonsteroidal anti-in-
flammatory drugs for cataract surgery patients
Stodola, Ellen. JCRS article reviews uses of NSAIDS. EyeWorld 21(10):46
A recent review, published in the Journal of Cataract and Refractive Surgery (JCRS), delves into preoperative, in- traoperative, and postopera- tive uses of NSAIDS, as well as mechanism of action, cu- rrently available NSAIDs, uses in certain cases, and special considerations for glaucoma patients.
The article reviews literatu- re on available NSAIDs and use in cataract surgery. One important indication is for postoperative use in cata- ract surgery for treatment of cystoid macular edema (CME). There is also some evidence to support the use of preoperative NSAIDs in preventing CME.
Richard Hoffman, MD, Euge- ne, Oregon, discussed the paper and its importance.
“Originally, this paper was a response to an article that was published in Ophthalmo- logy by its retina committee,” he said. The conclusion from that paper, he said, was that the visual acuity in patients with CME was no different at 3 months, which implied that physicians don’t need to treat patients with nonsteroi- dals if they have CME.
The concern surrounding this paper is that private insuran- ce companies and Medicare might look at the conclusions and determine that covera- ge for NSAIDs at the time of cataract surgery was unne- cessary. “This would make it harder for physicians to pres- cribe them to their patients,” Dr. Hoffman said.
Initially, this JCRS article was intended to be a white paper, Dr. Hoffman said, but it turned into a major review as a collaboration of the AS- CRS Cataract Clinical Com- mittee and the American Glaucoma Society.
The goal of the paper is to be comprehensive as a re- view of nonsteroidal drugs for cataract surgery, to dis- cuss the benefits of nonste- roidals, to discuss their use for CME, to talk about the di- fferent treatment paradigms in terms of whether we should be using them for all patients, and to review their potential adverse reactions.
The concern was that there was a paper from a major or- ganization saying that final vi- sual acuity doesn’t matter at 3 months, Dr. Hoffman said.
“Surgeons have the option of using them or not but it’s been shown to reduce the incidence of CME,” he said. “Even if final visual acui- ties are no different at three months, patients who deve- lop CME are distressed pa- tients, so if you can avoid that, it’s good.” Patients who develop CME are not happy because they have impaired vision, he said. “If you tell them it will resolve in 2 to 3 months, some might be OK with it, but others might be angry and distrustful.”
The point of the paper, Dr. Hoffman said, was to give an overview of how nonsteroi- dals work, discuss what all the available ones and po- tencies are, and talk about their benefits.
Nonsteroidals are used in- traoperatively or right befo- re surgery to keep the pupil dilated so that the cataract surgery goes routinely, Dr. Hoffman said. They help with pain control in surgery, and if used before surgery for a few days, there’s a higher likelihood of preventing CME. These can also be used after surgery and can be used in place of steroids, especially for patients who can’t take topical steroids, he added.
This paper was a collabora- tion of more than a dozen surgeons, each with a diffe- rent perspective, Dr. Hoff- man said, and one or two did not use nonsteroidals routi- nely. Within the paper, it was stated that there are diffe- rent ways to use nonsteroi- dals. Some physicians don’t use them at all, some just for high-risk patients, and some routinely in all patients, Dr. Hoffman said. Less than 2% and possibly less than 1% of cataract patients will de- velop CME. He stressed that the goal was for the paper to apply to everyone and to not imply that nonsteroidals are an absolute necessity.
Considerations for glauco- ma are included in the pa- per. Originally, this was only
going to be an ASCRS paper, Dr. Hoffman said, but then the American Glaucoma So- ciety got involved. There were several main points in the paper pertaining to glau- coma. The first is whether or not patients with glauco- ma have a higher incidence of CME because of all the medications they were ta- king. A lot of these patients are on prostaglandin ago- nists, Dr. Hoffman said, and it’s been shown that these have slightly higher risk of CME because prostagland- ins break down the vascula- ture barrier. “These patients should be treated with a nonsteroidal at the time of cataract surgery, especially if the prostaglandin cannot be stopped,” he said. Pa- tients who have glaucoma associated with pseudoe- xfoliation, have a higher in- cidence of small pupils and iris trauma from the sur- gery. This could potentially lead to a more complicated surgery, increased inflam- mation, and a higher rate of CME, so they should be treated with nonsteroidals.
NSAIDs have been used for nearly 30 years with success, the paper concluded. They have numerous uses in ca- taract surgery, both in com- plicated and routine cases. The paper is published in the September issue of JCRS.
- Hoffman RS, et al. Cataract surgery and nonsteroidal anti-inflammatory drugs: a combined ASCRS Cataract Clinical Committee and AGS re- view J Cataract Refract Surg. 2016;42(9): 1368-1379.
- Editors’ note: Dr. Hoffman has no financial interests related to his comments. This article was first pu- blished in the October 2016 issue of EyeWorld (21:46). It is used here with
- Reprinted with permission of the Journal of Cataract & Refractive Sur- gery©