Inhibition of blood-aqueous humor barrier breakdown with diclofenac. A fluorophotometric study

Ketorolac, prednisolone, and dexamethasone for postoperative inflammation

This 6-week, partially masked, three-arm, multicenter study was conducted to evaluate the postoperative anti-inflammatory efficacy of ketorolac, a cyclooxygenase inhibitor. The study setting was the clinical practice of six ophthalmic surgeons. The study enrolled 157 candidates for routine extracapsular cataract extraction or phaco-emulsification and posterior-chamber intraocular lens implantation. Patients who received any glucocorticoid or cyclooxygenase inhibitor within 1 week of surgery were excluded. All patients were treated with solutions of 0.5% ketorolac, 1% prednisolone acetate, or 0.1% dexamethasone instilled into the operative eye three times daily from 1 day before surgery to 4 weeks after surgery. Efficacy variables included the signs of anterior-segment inflammation, primarily cells and flare in the anterior chamber, as observed by slit-lamp biomicroscopy; fluorescein leakage across the blood-aqueous barrier as measured by fluorophotometry; and the rating of efficacy by the investigator. No significant differences were seen between ketorolac and either glucocorticoid in cells and flare. No significant differences were found in other signs of inflammation, except conjunctival hyperemia and Descemet's folds at week 2. Ketorolac showed significantly greater efficacy than the glucocorticoids against blood-aqueous barrier breakdown at day 5 and week 2, as demonstrated by the difference in fluorescein concentration between the operated and nonoperated eyes. Investigators did not detect any significant difference in rating for overall effectiveness and acceptability. These findings support the use of ketorolac as an alternative to glucocorticoids for the treatment of postoperative inflammation.

Effect of 3.0 mm tunnel and 6.0 mm corneoscleral incisions on the blood-aqueous barrier

PURPOSE

To study of the effect of silicone intraocular lens (IOL) implantation using a 3.0 mm tunnel incision with that of implantation though a 6.0 mm corneoscleral incision after phacoemulsification in human eyes.

SETTING

Department of Ophthalmology, University of Köln, Germany.

METHODS

In a prospective, randomized clinical study, 50 patients with senile cataract had phacoemulsification and IOL implantation through a 3.0 mm tunnel or a 6.0 mm corneoscleral incision. To assess blood-aqueous barrier (BAB) disruption, preoperative and postoperative sodium fluorescein concentrations in the anterior chamber were measured with the Fluorotron Master II. Diclofenac sodium 0.1% was applied to the operative eyes five times a day for 5 days. The contralateral eyes served as controls.

RESULTS

There was no significant between-group difference in sodium fluorescein concentrations in the 5 days after surgery.

CONCLUSION

The findings underline our clinical impression that BAB disruption 5 days after surgery does not differ significantly with the type and length of scleral incision used for IOL implantation.

Diffusion coefficient through the blood-aqueous barrier using a standard protocol

AIMS/BACKGROUND

Comparison of the diffusion coefficient through the blood-aqueous barrier of healthy volunteers measured in different cities with identical fluorophotometers using a standardised protocol.

METHODS

Healthy volunteers aged between 20 and 70 years were studied in seven European cities. The fluorescein concentration in the anterior segment of each eye was measured with a commercial scanning fluorophotometer 30 and 40 minutes after intravenous fluorescein. The decay of non-protein bound fluorescein concentration in blood plasma was determined with the use of three blood samples taken at 7, 15, and 55 minutes after injection. The diffusion coefficient through the blood-aqueous barrier was calculated from the ratio between the fluorescein concentration in the anterior chamber and the time integral of non-protein bound fluorescein concentration in plasma using specially developed software.

RESULTS

The mean values of the diffusion coefficient (SD) (X10(-4) min-1) were 4.76 (1.51) (n = 20, Brussels), 5.48 (2.33) (n = 17, Coimbra), 3.47 (2.09) (n = 12, Cologne), 6.09 (2.77) (n = 21, Frankfurt), 3.85 (1.59) (n = 11, Ghent), 4.99 (1.69) (n = 23, Leiden), and 4.87 (1.05) (n = 20, Madrid). The values between centres were similar (Kruskal-Wallis test p > 0.05) except for Cologne and Frankfurt (p = 0.013). No differences were found when repeating measurements (four centres, interval time 1-8 months, Wilcoxon paired test p > 0.39).

CONCLUSION

The diffusion coefficients had similar values and standard deviations. The concerted action demonstrated the usefulness of a standardised protocol.

Pretreatment with topical diclofenac sodium to decrease postoperative inflammation

PURPOSE

Anti-inflammatory medications are traditionally administered to the eye only postoperatively for control of inflammation. Because the presumed mechanism of action of nonsteroidal anti-inflammatory drugs (NSAIDs) is to inhibit the formation of prostaglandin mediators of inflammation, the author studied the effect that pretreatment with an NSAID had on postoperative inflammation.

METHODS

In a prospective study, 60 patients scheduled for phacoemulsification with silicone lens implantation were randomly assigned to receive either (1) pretreatment with one drop of diclofenac sodium 0.1% four times per day for the 3 days before surgery plus one drop of diclofenac sodium 0.1% every 15 minutes for four doses, beginning 1 hour before surgery along with the dilating drops; (2) no pretreatment, but one drop of diclofenac sodium 0.1% every 15 minutes for four doses beginning 1 hour before surgery along with the dilating drops; or (3) no diclofenac sodium drops at all before surgery. No anti-inflammatory medications were given either during or immediately after surgery, and all patients were begun on a regimen of one drop of diclofenac sodium 0.1% to the operated eye four times per day after being examined on the first postoperative day. Postoperative inflammation was measured on the first postoperative day and at 1 week with a laser cell and flare meter.

RESULTS

On the first postoperative day, the mean flare score for group A was 25.59 photons/millisecond; for group B, 29.69 photons/millisecond; and for group C, 33.07 photons/millisecond. The difference between groups A and C was statistically significant. The differences between groups A and B and between groups B and C were not statistically significant. There was no statistically significant difference for cell scores at 1 day or for cell or flare scores at 1 week.

CONCLUSIONS

The pretreatment with an NSAID before cataract surgery can reduce the amount of initial postoperative inflammation.

Effectiveness of diclofenac eyedrops in reducing inflammation and the incidence of cystoid macular edema after cataract surgery

PURPOSE

To evaluate the effectiveness of diclofenac eyedrops in reducing inflammation and the incidence of angiographic cystoid macular edema (CME) after cataract surgery and intraocular lens (IOL) implantation.

SETTING

Eye Clinic, Institute of Biomedical Sciences, San Paolo Hospital, Milan, Italy.

METHODS

Eighty-eight patients having cataract extraction were enrolled in a randomized clinical trial: 42 were given diclofenac eyedrops and 46, placebo. Postoperative inflammation in both groups was graded for 6 months using a dedicated system.

RESULTS

Eight patients (9%) had evidence of angiographic CME approximately 1 month after surgery: seven of these were in the placebo group (P = .039). This difference was not significant 3 and 6 months postoperatively. The signs of ocular inflammation were greater in the eyes receiving placebo; the difference was particularly evident up to 1 week after surgery. There was no significant difference in visual acuity between the two groups at any follow-up point, but the contrast sensitivity of the eyes that received diclofenac improved significantly at 10.5 cycles per degree 1 month postoperatively.

CONCLUSION

Diclofenac eyedrops effectively reduced ocular inflammation and the occurrence of angiographic CME after cataract surgery.

Efficacy and tolerance of diclofenac sodium 0.1%, flurbiprofen 0.03%, and indomethacin 1.0% in controlling postoperative inflammation

PURPOSE

To compare the anti-inflammatory effect of diclofenac sodium 0.1% ophthalmic solution, flurbiprofen 0.03% ophthalmic solution, and indomethacin 1.0%.

SETTING

Department of Ophthalmology, University of Köln, and Bundesknappschaftskrankenhaus, Sulzbach, Germany.

METHODS

One hundred seventeen patients enrolled in this prospective, randomized, double-masked, and parallel-group study had phacoemulsification and intraocular lens implantation and received one of the three solutions. Preoperatively at day 1 and postoperatively at day 4 or 5 and day 12, 13, or 14, they were examined by slitlamp, applanation tonometry, and laser flare meter.

RESULTS

Anterior chamber flare reduction from baseline was significantly greater in the diclofenac group than in the flurbiprofen group (P = .022). Patients in the diclofenac group had significantly less burning and stinging than those in the flurbiprofen and indomethacin groups at postoperative days 4-5 and 12-14 (P = .001).

CONCLUSION

Diclofenac sodium appeared to be more potent than flurbiprofen in controlling intraocular inflammation after cataract surgery and appeared to be locally tolerated better than flurbiprofen and indomethacin.

Effect of indomethacin-coated posterior chamber intraocular lenses on postoperative inflammation and posterior capsule opacification

We implanted indomethacin-coated intraocular lenses (IOLs) in rabbit eyes to ascertain how the sustained release of the drug affects postoperative inflammation and posterior capsule opacification (PCO). A preoperative resolution test showed that 1% indomethacin-coated IOLs placed in balanced salt solution released a mean 14.0 +/- 0.6 micrograms of the drug within 24 hours. Postoperatively, aqueous flare intensity in eyes with 0.1% indomethacin-coated IOLs and in eyes with 1.0% indomethacin-coated IOLs was significantly less at day 2 and at days 2 and 3, respectively, than in control eyes with uncoated lenses. In another group of eyes, histopathological examination showed that those with 1.0% indomethacin-coated lenses had significantly less PCO than the contralateral control eyes with uncoated IOLs.

Efficacy of diclofenac sodium solution in reducing discomfort after cataract surgery

Two hundred consecutive patients were enrolled in a randomized, prospective clinical trial evaluating the efficacy of diclofenac sodium (Voltaren Ophthalmic) in reducing patient discomfort after cataract surgery. Other factors evaluated were the effect of preoperative flurbiprofen (Ocufen) in preventing intraoperative miosis and on postoperative discomfort and the effect of incision size and intraocular carbachol (Miostat) on postoperative comfort. Diclofenac significantly reduced discomfort during the first 24 hours after surgery but not two to three days postoperatively, although there was a trend toward reduction. Flurbiprofen given preoperatively did not affect postoperative discomfort. It also did not affect pupil size at the start of surgery but did reduce intraoperative miosis. Incision size (5.2 mm versus 7.0 mm) had no effect on discomfort. Miostat did not affect discomfort, although there was a trend toward more discomfort. The results indicate that topical diclofenac, given immediately after cataract surgery, significantly reduces discomfort during the first 24 postoperative hours.

A comparative trial between diclofenac-gentamicin and betamethasone-neomycin drops in patients undergoing cataract extraction

Eighty patients were randomised in a single-masked parallel-group study to receive topically either the test drug, a diclofenac and gentamicin combination, or a betamethasone and neomycin combination after routine cataract extraction and intraocular lens implantation. Each group was assessed over a 6 week period for post-operative inflammation. The two drug combinations were equally effective in suppressing inflammation in the early post-operative stages and the diclofenac-gentamicin combination was slightly more effective in the later stages. The test drug was well tolerated and showed no adverse effects. We feel it is an effective and relatively safe drug which has a role as an anti-inflammatory agent after cataract extraction and has potential advantages in certain circumstances.

In vitro corneal permeability of diclofenac sodium in formulations containing cyclodextrins compared to the commercial product voltaren ophtha

The influence of different cyclodextrin derivatives on the in vitro permeability of diclofenac sodium through pig cornea was investigated and compared to the commercial product Voltaren ophtha. (Hydroxypropyl)-beta-cyclodextrin (HP beta CD) and two amorphous methylated cyclodextrins with different degrees of substitution were used. In hemolysis studies on human erythrocytes, the hemolytic activity of the different cyclodextrins and the drug was assessed. It was shown that HP beta CD reveals the most favorable toxicological properties. A decrease in the hemolytic activity of diclofenac was yielded by adding HP beta CD. In the permeability experiments the dependency of the permeability coefficients and lag times on the type of cyclodextrin and pH of the solutions were examined. A solution containing HP beta CD buffered in the pH range 6.5 to 7 is proposed as a useful eye drop formulation. All cyclodextrin formulations showed advantages as compared to Voltaren ophtha.

Efficacy of diclofenac sodium ophthalmic solution versus placebo in reducing inflammation following cataract extraction and posterior chamber lens implantation

One hundred forty-eight patients were enrolled in a randomized, prospective, placebo-controlled clinical trial evaluating the efficacy of diclofenac sodium (Voltaren Ophthalmic) in reducing ocular inflammation following extracapsular cataract extraction with posterior chamber intraocular lens implantation. Eligible patients were enrolled and randomized (2:1 diclofenac:placebo) if the sum of anterior chamber cells plus flare one day postoperatively (baseline) was at least four. None of the patients received concomitant steroidal anti-inflammatory treatment. The 99 patients receiving diclofenac sodium had significantly greater improvement from baseline in summed flare plus cell score than the 49 placebo patients at two to five days and seven to nine days after baseline. Similarly, diclofenac sodium patients had significantly less post-baseline conjunctival erythema and ciliary flush than placebo patients. Significantly more diclofenac sodium patients than placebo patients showed moderate to marked improvement from baseline in overall assessment of inflammatory response. Forty-nine percent of placebo patients but only 17% of diclofenac patients were considered therapeutic failures (P < .001). By five to seven days, 82% of diclofenac sodium patients and 59% of placebo patients had corrected visual acuities of 20/40 or better (P < .001). There were no clinically important differences in mean intraocular pressure at any visit.

Dexamethasone versus diclofenac sodium eyedrops to treat inflammation after cataract surgery

We compared the postoperative anti-inflammatory effect of diclofenac sodium 0.1% and dexamethasone phosphate 0.1% in a prospective, randomized, double-masked pilot study. Anterior chamber inflammation was evaluated by measuring aqueous flare and cells with a laser flare-cell meter at one, three, 12, 30, and 60 days after cataract surgery. Flare values in the two groups did not significantly differ at any time, nor did aqueous cell counts at one, three, 12, and 60 days after surgery. At 30 days, however, cell count was significantly lower in the diclofenac group. Diclofenac sodium seems to be as potent as dexamethasone phosphate, as good as anti-inflammatory agent, and may replace corticosteroid therapy after cataract surgery.

Flurbiprofen 0.03% for the control of inflammation following cataract extraction by phacoemulsification

We conducted a double-masked, vehicle-controlled study to evaluate the anti-inflammatory effect of topical flurbiprofen in cataract surgery by phacoemulsification and implantation of a posterior chamber intraocular lens. The 233 patients were randomized to receive either flurbiprofen or vehicle immediately prior to and for two weeks following surgery. No concomitant corticosteroid use was allowed. The flurbiprofen group had significantly less anterior chamber cells and flare at day 7 and significantly less conjunctival erythema, corneal edema, and lid edema at day 14. The investigator's global effectiveness rating was higher in the flurbiprofen group at day 14. Blood-aqueous barrier disruption, as measured by aqueous fluorophotometry, was statistically significantly diminished in the flurbiprofen group. Burning and stinging were rated significantly greater in the flurbiprofen group than in the vehicle group. Foreign-body sensation and photophobia were significantly more severe in the vehicle group than in the flurbiprofen group. Flurbiprofen provided postsurgical anti-inflammatory efficacy in clinical signs of inflammation and in blood-aqueous barrier disruption, and also showed improved subjective signs.

Ocular diclofenac. A review of its pharmacology and clinical use in cataract surgery, and potential in other inflammatory ocular conditions

Diclofenac sodium is a potent nonsteroidal anti-inflammatory drug with analgesic activity. When instilled as a topical 0.1% solution in a limited number of patients undergoing cataract surgery, diclofenac limits surgically induced miosis, reduces signs of ocular inflammation, does not cause elevations in intraocular pressure, and reduces the occurrence and severity of cystoid macular oedema. Preliminary findings suggest a niche for topical diclofenac in other ocular inflammatory conditions such as iritis, episcleritis and conjunctivitis, although its efficacy in these areas awaits confirmation. The drug appears well tolerated, apart from a transient burning sensation after instillation in some patients. Ocular diclofenac thus appears well suited as a local anti-inflammatory adjunct to cataract surgery, and may be useful in some other inflammatory ocular conditions.

Cyclo-oxygenase inhibitors in ophthalmology

Cyclo-oxygenase inhibitors, which are formulated as ophthalmic eyedrop preparations, have recently become commercially available for use by ophthalmologists in the United States to inhibit intraoperative miosis during cataract surgery and to prevent postoperative inflammation. In addition, they are available worldwide as ocular antiinflammatory drugs and are used in the prevention and treatment of pseudophakic and aphakic cystoid macular edema. Understanding the rationale behind the use of these agents requires an understanding of the pathophysiology of the cyclo-oxygenase inhibitors. In this review recent advances in laboratory and clinical science are emphasized. The role of COIs during and following surgery is examined.