CASE STUDY

DSEK With NSAIDs for Treating Pre-existing CME

BY DOUG KATSEV, M.D.

A 71-year-old female was sent to me as a referral case. Her visit was a result of a cataract surgery gone badly with cystoid macular edema (CME) and corneal edema that had not resolved in 6 months despite frequent steroid use.

The treating cataract surgeon had used frequent steroids, both topical prednisolone acetate (Pred Forte, Allergan) and injectable triamcinolone acetonide. The patient had also received sodium chloride ophthalmic ointment (Muro-128, Sochlor) q.i.d. for the previous 4 months without improvement. CME remained as shown by optical coherence tomography (OCT) scans, and corneal edema persisted. She was unhappy with the results and lack of improvement of her eye conditions and came to me for a second opinion.

Case and Treatment

The patient's vision was 20/25 OD and 20/400 OS. The left eye had corneal edema and a posterior chamber IOL. The OCT, used to take serial measurements in order to assess treatment efficacy, was 302 μm in the left eye. After looking at the OCT and the guttata on the right cornea, I decided this case could be treated with aggressive nonsteroidal anti-inflammatory drugs (NSAIDs), Acular LS (Allergan, Irvine, Calif.) and Descemet's stripping with endothelial keratoplasty (DSEK). Steroids were used in the postoperative period for 4 weeks and maintained at once a day for the following 3 months.

Standard clear-corneal DSEK was performed with very good tissue. The patient was treated with Acular LS q.i.d. for the week prior to surgery and 8 weeks following surgery.

The patient's vision improved from 20/400 to 20/100 the first 2 weeks, with the OCT measurement decreasing to 298 μm. Six weeks post surgery, vision was 20/50 OS and the OCT measurement had decreased to 278 μm. The aggressive NSAID q.i.d. regimen was continued and the steroids were tapered to q.d.

Figure 1A. OCT before DSEK correction and treatment with NSAID. Figure 1B. OCT after treatment.

On the eighth week postop, vision had improved to 20/30 and the OCT measurement had decreased to 233 μm. The patient's vision continued to improve and by 10 weeks postop, the patient was able to see some of the 20/20 line.

Treatment Choice

The patient had CME by OCT measurement along with fairly traumatic surgery, causing inflammation of the retina. Treatment of CME with NSAIDs is part of my standard treatment in patients in these situations. I have found that steroids help some, but the addition of non-steroidals as a combination works well to reduce swelling at the back of retina. Wittpenn et al.'s study demonstrates that, even in a non-traumatic case, Acular LS decreases CME.¹ This helps to show how important the use of NSAIDs is in traumatic cases.

With frequent use of steroids, which is the other treatment for CME, there is an increase in IOP. Certainly the addition of NSAIDs is a much safer route and, I feel, a more effective one. There have been issues with NSAIDs and corneal melts in the past, but in my experience over the last 10 years, with the medicine available, I have not seen a single melt.

Conclusion

My opinion is that it is more effective to choose a specific combination therapy rather than a class of drugs when trying to improve visual outcomes in patients with CME, especially now that patients are unsatisfied with delayed or suboptimal visual improvement after surgery. Good results from DSEK and NSAIDs helped this patient recover almost fully. Ten weeks after surgery, her left eye had reached the visual acuity of her right eye. OM

Reference

1. Wittpenn J, Silverstein SM, Hunkeler JD, et al. Masked comparison of Acular LS Plus steroid vs. steroid alone for the prevention of macular leakage in cataract patients. Paper presented at: Joint Meeting of the American Academy of Ophthalmology and Asia Pacific Academy of Ophthalmology; Nov. 10, 2006; Las Vegas, Nev.

Douglas Katsev, M.D. is in private practice at the Sansum Santa Barbara Medical Foundation Clinic in Santa Barbra, Calif. He specializes in refractive and corneal surgery. Dr. Katsev is a consultant for Allergan, AMO and ISTA.