Rx Perspective
Today's Approach to Inflammation
Experts discuss why the steroid/NSAID combination is the best way to preserve macular function after cataract surgery.
BY OPHTHALMOLOGY MANAGEMENT STAFF

During this year's annual meeting of the American Society of Cataract and Refractive Surgery, Allergan/AMO brought together a panel of experts to discuss perioperative control of infection and inflammation in cataract surgery. Participants shared their expertise, real-world experience and preferred practice patterns. What follows are highlights from the discussion on using steroids and nonsteroidals to most effectively control inflammation.

Moderator Calvin Roberts, M.D., began the discussion by saying that the main goal of today's cataract surgery is giving patients the best possible uncorrected vision, both at distance and near. Many new technologies and techniques help them to accomplish that goal, he said, including multifocal and toric IOLs, relaxing incisions and post-op LASIK. "But what do all of these have in common?" he asked. "To a greater or lesser degree, they decrease contrast sensitivity."

That means cataract surgeons now have the added responsibility of preserving macular function so patients can experience the full benefit of surgery.

"We preserve macular function in two ways: by minimizing the production of intraocular prostaglandins, and by controlling intraocular inflammation. The recovery of visual acuity after cataract surgery is directly related to the amount and duration of postoperative inflammation," Dr. Roberts said.

NONSTEROIDALS THEN AND NOW

Dr. Roberts explained how surgeons first used nonsteroidals in cataract surgery to keep pupils dilated. Then, a series of studies showed that for routine amounts of inflammation, nonsteroidals could be as effective as steroids in controlling post-op inflammation. "In retrospect, those studies actually did us a disservice because they gave the impression that nonsteroidals were an alternative to steroids," he said. "If there's anything we've learned in the last 12 years, it's how different steroids and nonsteroidals are. Steroids act on phospholipase 2 and stop the conversion to arachadonic acid. Nonsteroidals act on cyclo-oxygenase to stop the conversion of arachadonic acid to prostaglandins."

Dr. Roberts continued to explain that once the amount of prostaglandins in the eye after cataract surgery was actually measured, it was clear that lower levels existed with use of nonsteroidals. Knowing that nonsteroidals blocked the arachidonic-acid-to-prostaglandins conversion more effectively than steroids, and that prostaglandins are the primary mediators of inflammation, surgeons then questioned why they began anti-inflammatory therapy only after surgery.

That question led to studies of whether patients could be treated preoperatively with nonsteroidals to inhibit cyclo-oxygenase and therefore limit the conversion of arachadonic acid to prostaglandins.

Dr. Roberts said in one such study that he conducted, "We found that the patients with 3 days of preoperative nonsteroidals had a statistically significant decrease in the amount of inflammation on the first postoperative day compared with those who only had them on the day of surgery, and particularly those who had no preoperative nonsteroidals. We measured this using a Kowa laser cell flare meter. But even without sophisticated equipment, you could see it. These eyes were quieter; the corneas were clearer; and there was less reaction in the anterior chamber."

STEROIDS AND NONSTEROIDALS: THE COMBINATION IS KEY

All of the panel members agreed that the most effective way to control inflammation, including cystoid macular edema (CME), is with the combination of steroids and nonsteroidals. "I said earlier that the key is to control both the amount and the duration of the inflammation," Dr. Roberts said. "I think of the nonsteroidal as helping me to control the amount, while the steroid helps me to control the duration. It's the use of them together that I find to be the most effective."

Francis Mah, M.D., agreed. "I use steroids starting postoperatively from day 1, and I use nonsteroidals starting 3 or 4 days prior to surgery 4 times a day. I have patients continue the nonsteroidals for 6 to 8 weeks post-op to get over that peak of the incidence of CME."

Stephen Pascucci, M.D., cited a similar protocol: "Three days prior to surgery, I begin Acular and Ocuflox, each 4 times daily. I continue that right through surgery. Beginning at about 10 days after surgery, I stop the steroid and the antibiotic, but continue with the nonsteroidal for at least 1 month afterward. That really gives me the type of coverage and anti-inflammatory control I like to see."

Dr. Roberts said a question he's often asked is whether it's OK to stop the steroids abruptly. "In my practice, we use it 4 times a day for a week then stop it," he said. Dr. Pascucci replied that there's no need to taper the steroids. "When you're using a nonsteroidal as a complement to the steroid, you can stop the steroid. You're not really abruptly stopping anti-inflammatory therapy; you're just stopping one type of anti-inflammatory therapy that's no longer necessary.

"And I agree that you really don't need the steroid beyond 1 week or so. I tend to stop mine at about day 10."

NONSTEROIDALS: THE ADDED BONUS OF ANALGESIA

The panel also discussed how nonsteroidals make patients more comfortable. "They're more comfortable intraoperatively because I don't need to use preservative-free 1% lidocaine nearly as much as I used to," Dr. Pascucci said. "And postoperatively they're saying that they're not uncomfortable at all. Traditionally, I was hearing on the first day that the operative eye was picky."

Terrence O'Brien, M.D., said that because he uses 2% lidocaine gel after applying Acular, he doesn't need intracameral lidocaine unless he's going to extensively manipulate the uveal tract or iris. "We did a randomized study and found that even with placebo injected into the aqueous humor, patients were comfortable and the lidocaine intracamerally was providing little additional benefit," he said.

Dr. Roberts reinforced the importance of patient comfort: "Pain-free surgery is probably the best internal marketing that we have in our practice."