NSAIDs Find Favor in a Range of Uses

Getting the most from these versatile drugs.

BY JERRY HELZNER, SENIOR EDITOR

Nonsteroidal anti-inflammatory drugs (NSAIDs) may be on the verge of becoming the ophthalmic equivalent of aspirin.

Just as medical science continues to find new uses for aspirin, ophthalmologists are reporting excellent results using NSAIDs in a variety of new ways. This article will provide several examples of how doctors are expanding the range of utility for NSAIDs.

Though NSAIDs were originally indicated for pain and inflammation associated with cataract surgery, they are also proving their worth in many other situations. Doctors report using NSAIDs, almost always in combination with other drugs, in the treatment of eye allergies, corneal ulcers, corneal abrasions and other epithelial defects. NSAIDs are being used to reduce pain and increase patient comfort following LASIK or surface ablation procedures. Some ophthalmologists say NSAIDs can also play a role in the treatment of dry eye in those patients who find it difficult to tolerate cyclosporine (Restasis, Allergan) because of the stinging sensation they experience when the drug is instilled in the eye. Other ophthalmologists prefer to use a steroid in combination with cyclosporine.

A Key to CME Prevention

Edward J. Holland, M.D., professor of ophthalmology, University of Cincinnati, and director, cornea service, Cincinnati Eye Institute, says he uses NSAIDs in three ways: for preventing cystoid macular edema (CME) associated with cataract surgery, for treating CME and for pain management in post-surgical patients and for patients with epithelial disorders such as corneal abrasions.

Dr. Holland uses the pro-drug nepafenac ophthalmic suspension 0.1% (Nevanac, Alcon) as his NSAID of choice, citing its high level of penetration into the anterior chamber.

"About half of cataract surgeons are now using NSAIDs to prevent CME," says Dr. Holland, "and some of those doctors are only using NSAIDs for their high-risk patients, such as diabetics. I advocate using an NSAID for all cataract patients because all of these patients are at risk for CME, and even a mild case of CME can cause a significant reduction in the quality of a patient's vision."

Dr. Holland points out that NSAIDs are an effective treatment for CME but that even successfully treated CME can result in reduced vision quality.

John R. Wittpenn, M.D., of Ophthalmic Consultants of Long Island, was chief investigator in a recent 14-center, 546-patient study that demonstrated that even those cataract surgery patients with the lowest risk for CME should be treated with NSAIDs as a preventive measure. He used ketorolac tromethamine ophthalmic solution 0.4% (Acular LS, Allergan) in the study because of the large amount of study data available that demonstrate its efficacy and safety.

"We found that even those patients with a perfect lowrisk profile for cataract surgery ran a 2.5% chance of developing CME if the ketorolac was not administered pre- and postoperatively," asserts Dr. Wittpenn. "We found that ketorolac can virtually eliminate that risk and spare many patients the temporary vision reduction and long-term loss of contrast sensitivity that CME can cause."

Dr. Wittpenn recommends starting cataract patients on ketorolac four times a day 2 days prior to surgery. He also applies ketorolac at dilation. He puts patients on a postoperative regimen that includes ketorolac four times a day for three-and-a-half weeks along with prednisolone acetate (Pred Forte, Allergan) to quiet the eye.

Dr. Holland says he starts cataract patients at high risk for CME on nepafenac about a week prior to surgery and continues the regimen 4 to 6 weeks postop.

"There is evidence that CME can develop a month or more after surgery. We may need to think about extending the use of NSAIDs to 2 to 3 months postop with some patients," he adds.

Success With Corneal Ulcers

Keith Liang, M.D., F.A.C.S., medical director of The Center for Sight in Sacramento, Calif., has had a great deal of success in using bromfenac ophthalmic solution 0.09% (Xibrom, ISTA Pharmaceuticals) as an element in the treatment of corneal ulcers.

Dr. Liang cites one 51-year-old female with a history of thyroid disease, Sjögrens syndrome and arthritis who came to him complaining of pain and foreign-body sensation in her left eye. After examination revealed a serious corneal infection, Dr. Liang initiated therapy with moxifloxacin HCl ophthalmic solution 0.5% (Vigamox, Alcon) q.i.d.. A day later, with the patient continuing to complain about intense pain and photophobia, Dr. Liang added bromfenac b.i.d while continuing moxifloxacin.

At day 4, the patient reported tremendous improvement in pain and photophobia. At day 8, Dr. Liang added loteprednol etabonate ophthalmic suspension 0.5% (Lotemax, Bausch & Lomb) q.i.d. for 1 week. He continued the patient on bromfenac until day 21 to control inflammation and ensure the patient's comfort.

"I have used an NSAID multiple times in similar situations and it has worked out fine in terms of providing pain control and patient comfort," says Dr. Liang. "I find the twice-a-day dosing of Xibrom especially advantageous for these patients."

Both Dr. Liang and Dr. Wittpenn also advocate the use of an NSAID in conjunction with a mast-cell stabilizer to treat symptomatic eye allergies

"I prescribe the NSAID for use once a day mainly to help stop the itching and to keep the patient symptom-free," Dr. Liang says. "Here in northern California, we have many eye allergy patients who become symptomatic during the spring and fall seasons."

In addition, Dr. Liang uses NSAIDs as part of his therapeutic regimen for all cataract and refractive surgery patients.

Pain Reduction in Surface Ablation

Dr. Holland say that the increasing use of NSAIDs in pain-reduction regimens for surface ablation patients is a major factor in contributing to the trend toward more surface procedures.

"The great concern with LASIK is ectasia," he notes. "If you can perform a surface procedure with a good pain-reduction regimen, you avoid the possibility of ectasia. I also would not underestimate the pain management role of NSAIDs in cataract surgery, especially with patients who have clear-corneal or limbal incisions. These patients can be made much more comfortable with NSAIDs."

Dr. Holland thinks the reluctance of some ophthalmologists to use NSAIDs for more of their patients goes back to incidents of corneal melt associated with generic diclofenac sodium. He says the newer branded NSAIDs are much safer if used properly.

"You cannot just substitute an NSAID for a steroid in every situation," he cautions. "There are specific indications for each. I think we need to be aware of that and use NSAIDs where they are appropriate and safe." OM