Topical nonsteroidal anti-inflammatory drugs for ophthalmic use: a safety review

A randomized controlled trial comparing the efficacy of topical antibiotic steroid combination versus no treatment after fornix-incision strabismus surgery

PURPOSE

To compare comfort and inflammation in patients treated with postoperative topical antibiotic steroids in one eye versus no treatment in the other eye.

METHODS

This prospective, randomized single-masked study included all patients with planned symmetrical strabismus surgery via fornix incision. One eye was randomly assigned to topical postoperative tobramycin-dexamethasone and the other eye was not treated. Patient and parent questionnaires were administered, and two masked observers assessed conjunctival injection over the muscle and wound site.

RESULTS

A total of 70 patients completed at least 1 postoperative visit and were included. There was no statistically significant difference between the treatment eye and the no treatment eye in any of the studied parameters.

CONCLUSIONS

Postoperative topical antibiotic steroid did not prove to be superior to no treatment in uncomplicated fornix surgery with regard to patient comfort and inflammation. In those cases, consideration may be given to sparing the patient the inconvenience, cost, and potential complications of the topical medication.

A Case of Allergic Urticaria After Ophthalmic Nepafenac Use

A 21-year-old male patient with no history of systemic disease or drug use presented to our clinic with redness and pain in the right eye. Best corrected visual acuity was 20/20 in both eyes. Inflamed pinguecula was observed on slit-lamp examination and the patient was prescribed ophthalmic nepafenac eye drops. After instilling the drops that day and the next day, the patient presented again due to pruritus and rash. Upon consultation with the dermatology department, the patient was diagnosed with drug-induced allergic urticaria and the nepafenac drops were discontinued. Although urticaria has been reported as a side effect after systemic non-steroidal anti-inflammatory drug (NSAID) use, such a reaction has not been reported with an ophthalmic NSAID and ours is the first reported case of urticaria following ophthalmic nepafenac use. This unique case highlights the fact that ophthalmologists must also keep urticaria in mind as a potential side effect when prescribing this drug.

Topical Nonsteroidal Anti-Inflammatory Drugs in Uncomplicated Cataract Surgery: Effect of Sodium Naproxen

Purpose

To investigate whether topical nonsteroidal anti inflammatory drugs (NSAIDs) are useful, in the absence of concomitant corticosteroid therapy, in limiting postoperative inflammation after uncomplicated cataract surgery.

Methods

A total of 328 patients were enrolled in a prospective, randomized, double-masked, parallel-group, active-controlled study. Anterior chamber inflammation (ACI) was evaluated as the primary efficacy parameter. Only patients with moderate inflammation (ACI score of ≤4) the day after surgery were randomized and treated with NSAIDs. A novel topical formulation containing 0.2% sodium naproxen was compared with 0.1% diclofenac. Both were administered three times a day for 14 consecutive days. Ocular inflammation was measured after 7 and 14 days by using slit-lamp biomicroscopy. Safety parameters were also evaluated at the same time.

Results

Both treatments were equally effective in controlling postsurgical inflammation. No statistically significant differences between treatment groups were observed for the safety variables. No serious adverse events (AEs) occurred during the course of the study. The most frequent AE reported with naproxen was eye redness.

Conclusions

NSAIDs can effectively be used without concurrent administration of corticosteroids to control postoperative inflammation after uncomplicated cataract surgery. In addition, naproxen ophthalmic solution may be considered a suitable alternative to the currently available NSAIDs.

Intracameral Use of Nepafenac: Safety and Efficacy Study

PURPOSE

To test the intracameral safety of nepafenac and its efficacy in inhibiting prostaglandin synthesis during phacoemulsification surgery.

METHODS

The safety evaluation was conducted in normal eyes of rabbits, 0.1ml of 0.3% and 1% nepafenac was injected intracamerally. Extensive studies to detect adverse response ranged from a gross examination of eyes under slit lamp biomicroscope, fluorescein dye test, Schirmer tear test, test for corneal sensitivity, intraocular pressure measurement (IOP), specular microscopy, electroretinography(ERG), and histopathological examination of intraocular tissues. Efficacy of nepafenac was studied by intracameral injection of 0.1%, 0.3% nepafenac, nepafenac 0.3%+1% lignocaine, and 1% lignocaine alone, before phacoemulsification surgery and intraoperative mydriasis along with PGE2(ProstaglandinE2) secretion were recorded.

RESULTS

Single 0.1ml of 0.3% or 1% nepafenac did not significantly (p > 0.05) alter physiological parameters and histology of cornea, iris, and retina. Nepafenac 0.3% effectively inhibited PGE2 secretion. No significant (p > 0.05) prevention of miosis was recorded with 0.1% or 0.3% nepafenac. However, a combination of 0.3% nepafenac + 1% lignocaine and 1% lignocaine alone significantly (p < 0.05) arrested miosis during the intraoperative period.

CONCLUSION

An intracameral concentration of up to 1% nepafenac does not adversely affect the rabbit eye. Nepafenac fails to prevent miosis but inhibits prostaglandin release during phacoemulsification surgery.

Corneal antinociceptive effect of (-)-α-bisabolol

CONTEXT

(-)-α-Bisabolol (BISA) is a sesquiterpene alcohol widely used as scent in cosmetic preparations, perfumes, shampoos, toilet soaps and other toiletries with potential for use in the pharmaceutical area.

OBJECTIVE

To evaluate the corneal antinociceptive efficacy of BISA and to analyze the best solubilizing agent.

MATERIALS AND METHODS

Acute corneal nociception was induced by the local application of hypertonic saline (5 M NaCl; 20 μL) to the corneal surface of Swiss mice (n = 8/group) 60 min after topical treatment with solutions or ointment containing BISA (50-200 mg/mL). The number of eye wipes performed with the ipsilateral forepaw was counted for a period of 30 s. Control groups (vehicles) were included.

RESULTS

BISA (50, 100 or 200 mg/mL) solubilized with Tween 80 did not reduce the number of eye wipes. Animals treated with the ointment (BISA 50, 100 or 200 mg/mL; p < 0.001), as well the solution containing propylene glycol (BISA 100 mg/mL; p < 0.05), showed significant reduction in the number of nociceptive behaviours. Solutions containing propylene glycol and isopropyl myristate had no effects.

DISCUSSION AND CONCLUSION

BISA possess corneal antinociceptive activity. Although the ointment presented antinociceptive effect, it is concluded that BISA when associated with propylene glycol has better potential for corneal nociceptive pain since it is more comfortable to use, leading to greater acceptance by patients.

Molecular identification of viral agents associated with acute conjunctivitis: a prospective controlled study

Background

Viral conjunctivitis are the most frequent infections in ophthalmology clinics. The diagnosis is usually relying on clinical findings and medical history. However, topical antibiotics are often used unnecessarily addition to symptomatic treatment because of unsure agents. We aimed to detect the Adenovirus, Coxsackievirus and Enterovirus from conjunctiva and pharyngeal samples of patients.

Methods

The conjunctiva and pharyngeal samples of the patients with conjunctivitis were taken by Virocult transport media and kept at −80 ̊C up to study day. Adenovirus spp, Enterovirus 70 and Enterovirus 71, Coxsackie A24 and Coxsackie A16 were detected by real-time PCR. Samples from healthy health care workers of ophthalmology clinic were used for control group.

Results

A total of 176 samples (conjunctival and pharyngeal samples of 62 patient and 26 healthy subjects) were included. The mean age of 34 (55.7%) male and 27 (44.3%) female patients was 34 ± 17. Twenty five (40.3%) of the patients were receiving antibiotic drops at first visit. The main etiologic agent in conjunctival samples was found to be Adenovirus (46/62, 74.2%) followed by Enterovirus 70 (4/62, 6.4%) and Enterovirus 71 (4/62, 6.4%). Coxsackievirus 16 and 24 were also found in 2 patients (1/62 each, 1.6%). Pharyngeal samples were also positive for Adenovirus (20/62, 32.3%), Enterovirus 70 and 71 (7/62, 11.3% and 5/62, 8.1% respectively), Coxsackievirus 16 and 24 (2/62, 3.2% and 1/61, 1.6%).

Conclusions

It is very difficult in viral conjunctivitis to make clinical differentiation caused by different agents because of common clinical signs and symptoms. In routine clinical work, the viral conjunctivitis usually related with Adenovirus. But almost one fourth of the patients’ conjunctivitis were not related to Adenovirus, which shows the importance of the laboratory diagnostics. True diagnosis plays an important role on prevention of contamination and unnecessary use of antibiotics in viral conjunctivitis.

Efficacy and perioperative timing of bromfenac in the management of ocular discomfort after femtosecond laser-assisted laser in situ keratomileusis

PURPOSE

To evaluate the safety, efficacy, and appropriate perioperative timing of the use of topical bromfenac ophthalmic solution 0.07% after femtosecond laser-assisted laser in situ keratomileusis (LASIK).

SETTING

Keil LASIK Vision Center, Grand Rapids, Michigan, USA.

DESIGN

Prospective case series.

METHODS

Ocular discomfort was assessed 1, 2, and 5 hours postoperatively and the following morning using the Ocular Comfort Grading Assessment in patients treated with topical bromfenac 0.07% or artificial tears just before, just after, or before and after femtosecond laser-assisted LASIK. Visual outcomes and complications were noted up to 24 hours.

RESULTS

The study enrolled 64 patients (120 eyes). Patients who were treated with bromfenac 0.07% just before or before and after femtosecond laser-assisted LASIK showed the greatest statistically significant decrease in several discomfort scores within the first few hours in comparison with the control group. Two hours after surgery, the majority of patients who were treated before and after LASIK were sleeping comfortably. There were no significant differences in visual acuity; 1 day postoperatively, the uncorrected distance visual acuity was 20/20 in 106 eyes (89%) and 20/25 or better in 116 eyes (97%). At 3 months, all patients had binocular distance visual acuity of 20/20 or better and 86% of patients had 20/15 or better.

CONCLUSION

Ocular discomfort after femtosecond laser-assisted LASIK was reduced with a single dose of topical bromfenac 0.07% given immediately before surgery or given just before and after surgery and was typically minimal in all groups the morning after surgery.

Pseudophakic cystoid macular edema prevention and risk factors; prospective study with adjunctive once daily topical nepafenac 0.3% versus placebo

Background

Define the effectiveness of a topical non-steroidal anti-inflammatory drug (NSAID) added to topical steroid use after uncomplicated phacoemulsification for the prevention of pseudophakic cystoid macular edema (PCME) using a prospective, randomized, double-masked, placebo-controlled clinical study.

Methods

Eyes (1000) were randomized to placebo (497) or nepafenac 0.3% (503) used once daily, post-operatively for 5 weeks at two ophthalmology clinics. Diagnosis of PCME was made by clinical, ocular coherence tomography (OCT), and with fluorescein angiography confirmation. Correlation of PCME to NSAID use and the presence of pre-operative risk factors for PCME were assessed including, contralateral PCME, diabetic retinopathy, retinal vein occlusion, macular hole, epiretinal membrane, macular degeneration, retinal detachment repair, and prostaglandin use.

Results

PCME was the most common complication associated with routine cataract surgery (4.2% with PCME risk factors, 2.0% with risk factors excluded). Topical nepafenac 0.3% significantly reduces the incidence of PCME compared to placebo when used after routine cataract surgery (p = .0001). When patients with pre-operative risk factors are excluded, the incidence of PCME between treatment and placebo groups is equivalent (p = 0.31). PCME relative risk (RR) was most significant in contralateral PCME (RR 19.5), diabetic retinopathy (RR 13.1), retinal vein occlusion (RR 12.9), macular hole (RR 7.7), and epiretinal membrane (RR 5.7). Prostaglandin use and previous retinal detachment were not shown to increase risk.

Conclusion

Pseudophakic cystoid macular edema is common after phacoemulsification cataract surgery. Topical nepafenac 0.3% reduces PCME in patients with pre-operative risk factors for PCME compared to placebo but shows no benefit in patients without pre-operative risk factors.

Trial registration

NIH ClincalTrials.gov retrospectively registered January 15, 2017, NCT03025945.

Exponential Decay Metrics of Topical Tetracaine Hydrochloride Administration Describe Corneal Anesthesia Properties Mechanistically

PURPOSE

To identify pharmacodynamic (PD) and pharmacokinetic (PK) metrics that aid in mechanistic understanding of dosage considerations for prolonged corneal anesthesia.

METHODS

A rabbit model using 0.5% tetracaine hydrochloride was used to induce corneal anesthesia in conjunction with Cochet-Bonnet anesthesiometry. Metrics were derived describing PD-PK parameters of the time-dependent domain of recovery in corneal sensitivity. Curve fitting used a 1-phase exponential dissociation paradigm assuming a 1-compartment PK model. Derivation of metrics including half-life and mean ligand residence time, tau (τ), was predicted by nonlinear regression. Bioavailability was determined by area under the curve of the dose-response relationship with varying drop volumes.

RESULTS

Maximal corneal anesthesia maintained a plateau with a recovery inflection at the approximate time of predicted corneal drug half-life. PDs of recovery of corneal anesthesia were consistent with a first-order drug elimination rate. The mean ligand residence time (tau, τ) was 41.7 minutes, and half-life was 28.89 minutes. The mean estimated corneal elimination rate constant (ke) was 0.02402 minute. Duration of corneal anesthesia ranged from 55 to 58 minutes. There was no difference in time domain PD area under the curve between drop volumes.

CONCLUSIONS

Use of a small drop volume of a topical anesthetic (as low as 11 μL) is bioequivalent to conventional drop size and seems to optimize dosing regiments with a little effect on ke. Prolongation of corneal anesthesia may therefore be best achieved with administration of small drop volumes at time intervals corresponding to the half-life of drug decay from the corneal compartment.

Systemic side effects of eye drops: a pharmacokinetic perspective

When administering eye drops, even when completely correctly applied, several routes of absorption are possible and excess amounts can sometimes cause an unwanted systemic bioavailability of the drops when not completely absorbed into the eye. Furthermore, the concentration of active ingredients in such medicinal preparations is usually very high, so that despite the correct application of the recommended dose, considerable amounts may be absorbed in an unwanted manner through various routes. Children are subject to a much higher risk of systemic side effects because ocular dosing is not weight adjusted and physiological development (eg, liver status) differs from that of adults. There is a lack of information about pediatric dosing in the current literature. This review summarizes the most important clinically relevant systemic side effects that may occur during ophthalmic eye treatments. In this review, we discuss general pharmacokinetic considerations as well as the advantages, disadvantages, and consequences of administering drugs from some important drug groups to the eye.

Effects of Ototopic Steroid and NSAIDS in Clearing Middle ear Effusion in an Animal Model

OBJECTIVE: A model of otitis media with effusion (OME) has been developed in the Sprague-Dawley (SD) rat. This model was used to study the effects of an ototopic steroid and nonsteroidal anti-inflammatory drug (NSAID) on lipopolysaccharide (LPS)-induced OME.

STUDY DESIGN: Twenty-six rats were randomized into 4 groups: saline solution, LPS, NSAID + LPS, and steroids + LPS. Test substance was injected into the middle ear at 0, 2, and 4 hours. The effusion was collected at 2, 4, and 6 hours. Statistical analysis of effusion volume and albumin concentration was performed.

RESULTS: The LPS group demonstrated statistically significant increase in both effusion volume and albumin concentration compared with saline solution. Intergroup comparison revealed significantly less effusion volume in the steroid group and less albumin concentration in the NSAID group when compared with the LPS group.

CONCLUSIONS: Transtympanic steroid reduced LPS induced middle ear effusion while NSAID reduced albumin concentration in the rat model.

SIGNIFICANCE: Our results lend support to the current use of anti-inflammatory ototopicals in the treatment of inflammatory middle ear disease.

Bromfenac Eyedrops in the Treatment of Diabetic Macular Edema: A Pilot Study

Purpose

To evaluate the efficacy and safety of topical bromfenac in patients with newly diagnosed diabetic macular edema (DME).

Methods

In this pilot study including 17 patients with monocular, newly diagnosed DME, diagnosis of DME was established by the detection of retinal thickening at or within 500 μm of the center of the macula on ophthalmoscopic examination, according to the Early Treatment Diabetic Retinopathy Study classification. Central macular thickness (CMT) was determined by optical coherence tomography. Bromfenac sodium hydrate 0.9 mg/mL eyedrops were administered in the affected eye twice daily for 30 days. Primary endpoints were changes in best-corrected visual acuity (BCVA) and CMT at the end of therapy.

Results

Topical bromfenac significantly reduced mean CMT, from 465.41 ± 118.47 μm at baseline to 388.88 ± 152.63 μm posttreatment (p = 0.02). There was no significant change in BCVA and differences in mean macular volume fell just short of statistical significance (p = 0.06). Treatment was well-tolerated, and there were no topical or systemic side effects.

Conclusions

Topical bromfenac twice daily may play a role in the reduction of DME. These preliminary results warrant further larger multicenter studies to confirm our findings and establish whether topical bromfenac may be of long-term benefit in the treatment of DME.

Lipid nanoparticles (SLN, NLC): Overcoming the anatomical and physiological barriers of the eye - Part II - Ocular drug-loaded lipid nanoparticles

In the recent decades, various controlled delivery systems have been introduced with the aim to improve solubility, stability and bioavailability of poorly absorbed drugs. Among all, lipid nanoparticles gather interesting properties as drug or gene delivery carriers. These systems, composed either of solid lipids (SLN) or of solid and liquid lipids (NLC) stabilized with surfactants, combine the advantages of other colloidal particles such as polymeric nanoparticles, fat emulsions and liposomes avoiding their main disadvantages. Lipid nanoparticles represent an interesting approach for eye drug delivery as they can improve the corneal absorption of drugs enhancing their bioavailability. The Generally Recognized as Safe status of formulation excipients, the scaling-up facilities and the possibility of sterilization, make them suitable for industrial production. In this review, the latest findings, potential applications, and challenges related to the use of lipid nanoparticles for ocular drug delivery are comprehensively discussed.

Prospective randomised clinical trial to evaluate the safety and efficacy of nepafenac 0.1% treatment for the prevention of macular oedema associated with cataract surgery in patients with diabetic retinopathy

BACKGROUND/AIMS

This study evaluated nepafenac ophthalmic suspension 0.1% for prevention of macular oedema (MO) when used 90 days following cataract surgery in patients with diabetic retinopathy (DR).

METHODS

Randomised, double-masked, vehicle-controlled, parallel group study conducted at 32 centres across the world. Participants were patients with diabetes with non-proliferative diabetic retinopathy scheduled for cataract surgery with (posterior chamber) intraocular lens implantation. Patients were randomised to nepafenac ophthalmic suspension 0.1% or vehicle three times daily, beginning on the day before surgery and continuing through the last study visit (day 90 or early exit). All patients were instilled one drop of tobramycin 0.3% and dexamethasone 0.1% four times daily for 2 weeks after surgery. Primary efficacy end point was the percentage of patients who developed MO (defined as ≥30% increase in central subfield macular thickness from baseline) within 90 days following surgery. The secondary end point was mean change in best-corrected visual acuity (BCVA) from baseline to day 90.

RESULTS

A total of 175 patients were randomised, with 87 and 88 patients in the nepafenac and vehicle groups, respectively. A significantly greater percentage of eyes in the vehicle group (17.5%; 95% CI 9.9% to 27.6%) developed MO within 90 days following surgery compared with the nepafenac group (5.0%; 95% CI 1.4% to 12.3%, p=0.01). Mean change in BCVA from baseline to day 90 following surgery was greater in the nepafenac group (17.7±14.6 letters) relative to the vehicle group (14.3±13.9 letters), though the difference was not statistically significant (p=0.14). No new safety issues or trends were identified.

CONCLUSIONS

A 90-day nepafenac treatment regimen prevented MO after cataract surgery in patients with DR and demonstrated no safety issues within this study group.

TRIAL REGISTRATION NUMBER

NTC00782717 and NCT00939276.

Bioavailability and biochemical effects of diclofenac sodium 0.1% ophthalmic solution in the domestic chicken (Gallus gallus domesticus)

OBJECTIVE

To determine if topical ophthalmic diclofenac sodium 0.1% solution alters renal parameters in the domestic chicken, and to determine if the drug is detectable in plasma after topical ophthalmic administration.

ANIMALS

Thirty healthy domestic chickens.

PROCEDURES

Over 7 days, six birds were treated unilaterally with one drop of artificial tear solution (group 1), 12 birds were treated unilaterally (group 2) and 12 bilaterally (group 3) with diclofenac sodium 0.1% ophthalmic solution. Treatments were provided every 12 h in all groups. Pre- and post-treatment plasma samples from all birds were evaluated for changes in albumin, total protein, and uric acid. Post-treatment samples of all birds, collected 15 min post-administration, were analyzed by high-performance liquid chromatography with mass spectrometry for diclofenac sodium detection. A randomly selected renal sample from each group was submitted for histopathologic review.

RESULTS

Changes in pre- and post-treatment plasma albumin were significant (P < 0.05) in groups 2 and 3, but not for group 1. Pre- and post-treatment changes in total protein and uric acid were not significant for any group. Diclofenac sodium was not detectable (limit of detection = 0.10 ng/mL) in plasma samples from birds in group 1. Post-treatment concentration of diclofenac in group 3 was statistically greater than group 2 (P = 0.0008). Histopathologic changes did not identify diclofenac-induced acute renal tubular necrosis.

CONCLUSIONS

Ophthalmic diclofenac sodium 0.1% administered topically every 12 h in one or both eyes for 7 days is detectable in systemic circulation in the domestic chicken, but does not cause overt significant changes in plasma uric acid or total protein.

Topical nepafenac 0.1% alone versus prednisolone acetate 1% as postoperative anti-inflammatory agents in small gauge vitrectomy

AIM

To compare the efficacy of postoperative topical nepafenac (0.1%) with prednisolone acetate (1%) as anti-inflammatory agents in eyes undergoing Transscleral Sutureless Vitrectomy (TSV).

SETTINGS AND DESIGN

Prospective, double-blind, randomized, single center clinical study.

MATERIALS AND METHODS

Eighty eyes of 76 subjects, who underwent small gauge vitrectomy, were included in the study. The subjects who fulfilled the inclusion criteria were randomized to either topical nepafenac only (Group 1) or prednisolone acetate only (Group 2), to be used as postoperative anti-inflammatory agents. The subjects were reviewed on days 1, 30, and 90. Ocular and adnexal inflammation was appropriately graded using the standardized classification. Grading of ocular pain was done on the Visual Analog Scale (VAS).

STATISTICAL ANALYSIS

The Wilcoxon rank-sum test, using two-sided analysis, was used.

RESULTS

During the follow-up, both Group 1 and Group 2 did not have a significant difference related to the grade of the anterior chamber inflammation (P > 0.05) or adnexal inflammation (P > 0.05). Pain perception was less in the subjects in Group 1 as compared to subjects in Group 2, but was not statistically significant (P > 0.05).

CONCLUSION

Postoperative topical nepafenac was non-inferior to prednisolone acetate in reducing postoperative ocular inflammation in eyes undergoing TSV.

Ocular safety comparison of non-steroidal anti-inflammatory eye drops used in pseudophakic cystoid macular edema prevention

Non-steroidal anti-inflammatory drug (NSAID) eye drops are widely used to treat ocular inflammatory conditions related to ophthalmic surgical procedures, such as pseudophakic cystoid macular edema, and they have been used for off-label treatments. The most commonly used NSAIDs are diclofenac and ketorolac and the new molecules bromfenac and nepafenac have also been used. We used primary human keratocytes in cell culture in combination with a novel technology that evaluates dynamic real-time cytotoxicity through impedance analysis. This study also included classic cell viability tests (WST-1(®) and AlamarBlue(®)), wound healing assay, Hen's Egg Test and an ex vivo histopathological assay. NSAIDs were shown to have important cytotoxicities and to retard the healing response. Furthermore, the new eye drops containing bromfenac and nepafenac were more cytotoxic than the more classical eye drops. Nevertheless, no immuno-histochemical changes or acute irritation processes were observed after the administration of any eye drops tested. Due to cytotoxicity and the total absence of discomfort and observable injuries after the administration of these drugs, significant corneal alterations, such as corneal melts, can develop without any previous warning signs of toxicity.

Topical bromfenac for post-cataract extraction: A systematic review and pooled analysis

Bromfenac, a promising ophthalmic non-steroidal anti-inflammatory drug, has been used once daily for postoperative ocular inflammation and pain with satisfying efficacy, however, no integrated conclusion on its safety in clinical settings has been drawn. The purpose of this pooled analysis is to investigate the safety and efficacy of once daily bromfenac for ocular inflammation and pain among patients after cataract extraction (CE). MEDLINE, PsycINFO, Scopus, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched from inception to September 2014. Randomized controlled trials (RCTs) that studied topical bromfenac after CE were analyzed. Included studies were systemically reviewed, and effects were summarized using odds ratio (OR) with suitable effect model. Four RCTs involving 2294 participants were included. Topical bromfenac significantly increased the proportion of cleared ocular inflammation (OR, 2.37; 95% confidence interval [CI], 1.83–3.07; P <0.00001), ocular pain free (OR, 5.14; 95% CI, 4.07–6.49; P <0.00001), and decreased risk of overall adverse events (OR, 0.47; 95% CI, 0.38–0.58; P <0.00001). Bromfenac has been shown to be a safe and effective treatment for postoperative pain and inflammation in subjects undergoing CE. This is evidenced by the lower incidence of adverse events and the low scores for ocular pain and inflammation across multiple RCTs. However, demographics, co-morbidities of study participants, and the amount of co-medication were not reported, these possible sources of heterogeneity should be examined in future clinical trials.

Intravitreal triamcinolone acetonide in the treatment of ophthalmic inflammatory diseases with macular edema: a meta-analysis study

PURPOSE

To perform a meta-analysis of randomized controlled trials (RCTs) that compared the effects of treatment with intravitreal injections of triamcinolone acetonide (TA) with the standard of care for ocular inflammatory diseases.

METHODS

Medline database was searched for causes of macular edema terms in association with intravitreal triamcinolone. The primary outcome of interest included changes in best corrected visual acuity (BCVA) and central macular thickness (CMT). Pooled summary estimates for primary outcomes were calculated as weighted mean differences (WMD) either on a fixed- or random-effect model.

RESULTS

A total of 8 studies were included for quantitative analysis. Treatment with intravitreal TA showed improvement in BCVA compared with standard of care at 1 month (WMD, -0.09; 95% confidence interval [CI], -0.17 to -0.02), at 4 months (WMD, -0.09; 95% CI, -0.15 to -0.03), at 6 months (WMD, -0.13; 95% CI, -0.21 to -0.05), and in CMT at 1 month (WMD, -88.14; 95% CI, -105.86 to -70.43). Increased intraocular pressure (IOP) among patients treated with intravitreal TA was found at 4 months (WMD, 2.83; 95% CI, 1.96 to 3.70), persisting also at 12 months (WMD, 3.78; 95% CI, 2.97 to 4.59), compared with those receiving the standard of care. All outcomes are mostly equivalent at further follow-up times.

CONCLUSIONS

Intravitreal injections of TA may offer certain advantages over the standard of care for ocular inflammatory diseases, especially in the early stage of follow-up. However, it is necessary to take into account risks and benefits of TA treatment for ocular inflammatory diseases due to possible ocular hypertension elicited, in general, by intravitreal injection of corticosteroids.

Systemic absorption and adverse ocular and systemic effects after topical ophthalmic administration of 0.1% diclofenac to healthy cats

OBJECTIVE

To quantify plasma concentrations and determine adverse ocular, renal, or hepatic effects associated with repeated topical ophthalmic application of 0.1% diclofenac to healthy cats.

ANIMALS

8 healthy sexually intact male cats.

PROCEDURES

A randomized, placebo-controlled crossover study was conducted. A topical formulation of 0.1% diclofenac was administered 4 times/d for 7 days to 4 cats, and artificial tear (control) solution was administered to the other 4 cats. After a 12-day washout period, cats received the other treatment. Ophthalmic examinations were performed daily. Plasma samples were obtained on days 1 and 7 for pharmacokinetic analysis. A CBC, serum biochemical analysis, urinalysis, determination of urine protein-to-creatinine ratio, and determination of glomerular filtration rate were performed before the start of the study and after each 7-day treatment period.

RESULTS

Mild conjunctival hyperemia was the only adverse ocular effect detected. Maximal drug concentration and area under the curve were significantly higher on day 7 than on day 1. Diclofenac-treated cats had a significantly lower glomerular filtration rate than did control-treated cats after the second but not after the first treatment period, presumably associated with iatrogenic hypovolemia.

CONCLUSIONS AND CLINICAL RELEVANCE

Topical ophthalmic administration of 0.1% diclofenac was well tolerated in healthy cats, with only mild signs of ocular irritation. Detectable systemic concentrations of diclofenac were achieved with accumulation over 7 days. Systemic absorption of diclofenac may be associated with reduced glomerular filtration rate, particularly in volume-contracted animals. Topical ophthalmic 0.1% diclofenac should be used with caution in volume-contracted or systemically ill cats.

Drug utilization study in ophthalmology outpatients at a tertiary care teaching hospital

In view of the advancement in drug development and availability of new ocular therapeutics in the discipline of ophthalmology, we attempted to study the drug utilization and describe the prescribing practices of ophthalmologists in a tertiary care teaching hospital. Method. A prospective, cross-sectional, observational study was conducted on patients attending Outpatient Department of Ophthalmology for curative complaints. Prescriptions of 600 patients treated were analyzed by the WHO prescribing indicators and additional indices. Results. Analysis showed that the average number of drugs per prescription was 1.49. Percentage of drugs prescribed by generic name was 2.35%. Percentage of encounters with antibiotics was 44.83%. Percentage of drugs prescribed from National Essential drug list (NEDL)/National Formulary of India (NFI) was 19.48%. Patient's knowledge of correct dosage was 93.83%. Antimicrobial agents were the most commonly prescribed drugs followed by antiallergy drugs and ocular lubricants. Fluoroquinolones accounted for 60% of the total antimicrobial drugs, of which gatifloxacin was the most frequently prescribed fluoroquinolone. Conclusion. The study indicated an awareness of polypharmacy, but showed ample scope for improvement in encouraging the ophthalmologists to prescribe by generic name and selection of essential drugs from NEDL/NFI.

Corneal Debridement Update: Adjuvant Therapies and Wound Healing

Corneal debridement techniques have seen evolution in instrumentation and indication. Although the techniques themselves are simple and usually effective, there is often the need for adjuvant topical therapies to augment healing and/or prevent recurrence of disease. To better understand the requirement for adjuvant therapies, the current theories of corneal wound healing are reviewed.

Suprachoroidal injection of ketorolac tromethamine does not cause retinal damage

Rabbit right eyes were injected with 3 or 6 mg ketorolac tromethamine into the suprachoroidal space. Electroretinography results demonstrated no abnormal changes in rod cell response, maximum rod cell or cone cell mixing reaction, oscillation potential, cone cell response, waveform, amplitude, and potential of 30 Hz scintillation response in right eyes before injection, and at 1, 2, and 4 weeks after injection. There was no difference between left (control) and right eyes. Under light microscopy, the histomorphology of cells in each retinal layer was normal at 4 weeks following 6 mg ketorolac tromethamine administration. These results indicate that a single suprachoroidal injection of 3 or 6 mg ketorolac tromethamine into rabbits was safe. Suprachoroidal space injection appears to be safe.

Role of topical nepafenac in prevention and treatment of macular edema after vitreoretinal surgery

PURPOSE

To evaluate the effects of topical nepafenac in patients undergoing vitreoretinal surgery.

METHODS

One hundred and twenty eyes of 120 patients undergoing vitreoretinal surgery were randomized to receive either topical nepafenac 0.1% (60 eyes) or placebo (60 eyes) in this investigator-masked, randomized, comparative case series. Eyes were evaluated for Day 1 postoperative inflammation and 2-, 4-, 6-, and 8-week postoperative retinal thickness and best-corrected visual acuity.

RESULTS

Mean Day 1 inflammation grades of 0.95 ± 0.6 and 1.78 ± 0.7 were noted in patients taking nepafenac and placebo, respectively (P = 0.002). The nepafenac and placebo groups had mean central macular subfield thickness of 228.44 ± 29.27 μm and 236.21 ± 29.44 μm at 4 weeks (P = 0.172) and 205.35 ± 25.25 μm and 205.37 ± 24.90 μm at 8 weeks (P = 0.971), respectively. At 1 month, there was no statistically significant difference in the mean visual acuity between the nepafenac group (0.55 ± 0.16 decimal units) and placebo group (0.52 ± 0.17 decimal units).

CONCLUSION

Topical nepafenac was safe and reduced postoperative pain and inflammation in patients undergoing vitreoretinal surgery. However, its effect on reducing postoperative macular edema and improving visual acuity as compared with that of the standard postvitrectomy therapeutic regimen was equivocal.

Ketorolac therapy for the prevention of acute pseudophakic cystoid macular edema: a systematic review

To assess the effectiveness of ketorolac vs control for prevention of acute pseudophakic cystoid macular edema (CME). The following databases were searched: Medline (1950-June 11, 2011), The Cochrane Library (Issue 2, 2011), and the TRIP Database (up to 11 June 2011), using no language or other limits. Randomized controlled clinical trials (RCTs) were included that consisted of patients with acute pseudophakic cystoid macular edema, those comparing ketorolac with control, and those having at least a minimum follow-up of 28 days. In the four RCTs evaluating ketorolac vs control, treatment with ketorolac significantly reduced the risk of CME development at the end of treatment (≈ 4 weeks) compared to control (P=0.008; 95% confidence interval (0.03-0.58)). When analyzed individually, each individual study was statistically nonsignificant in its findings with the exception of one study. When the pooled relative risk was calculated, the large sample size of this systematic review led to overall statistical significance, which is attributable to the review's large sample size and not to the individual studies themselves. In this systematic review of four RCTs, two of which compared ketorolac with no treatment and two of which evaluated ketorolac vs placebo drops, treatment with ketorolac significantly reduced the risk of developing CME at the end of ≈ 4 weeks of treatment compared with controls. These results, however, should be interpreted with caution considering the paucity of large randomized clinical trials in the literature.

Corticosteroids versus NSAIDs on intraocular pressure and the hypertensive phase after Ahmed glaucoma valve surgery

PURPOSE

To compare the effect of topical steroids versus nonsteroidal anti-inflammatory drugs on intraocular pressure (IOP) and the hypertensive phase (HP) after Ahmed glaucoma valve surgery.

PATIENTS AND METHODS

Prospective, randomized, double-masked controlled trial. Twenty-eight consecutive consenting patients scheduled for Ahmed glaucoma valve surgery were randomized to receive either postoperative topical dexamethasone or ketorolac. The main outcome measure was IOP. Secondary outcomes included incidence of HP, visual acuity, number of glaucoma medications, postoperative complications, and subsequent procedures.

RESULTS

The mean postoperative IOP (in mm Hg) in the ketorolac versus dexamethasone arms respectively was as follows: 8.8±4.7 versus 10.0±4.5 at week 1 (P=0.500); 10.7±6.7 versus 17.5±10.4 at week 2 (P=0.053); 11.0±6.5 versus 18.0±7.3 at week 4 (P=0.013); 14.8±8.6 versus 17.5±5.2 at week 6 to 8 (P=0.323); and 14.8±9.6 versus 17.8±7.5 at week 10 to 12 (P=0.374). Four patients (31%) in the ketorolac arm versus 8 patients (53%) in the dexamethasone arm exhibited the HP (P=0.276). Wound leak was the most severe complication and there were 3 cases (23%) in the ketorolac group versus nil in the steroid group (P=0.087). Conjunctival retraction was observed in 8 patients (62%) in the ketorolac arm versus 2 patients (13%) in the dexamethasone arm (P=0.016).

CONCLUSIONS

Mean IOP was greater at all time points postoperatively in the steroid group with the difference between groups statistically significant at week 4. The nonsteroidal anti-inflammatory drug group showed greater wound-healing problems.

Topical ophthalmic NSAIDs: a discussion with focus on nepafenac ophthalmic suspension

The removal of diclofenac sodium ophthalmic solution as a viable pharmaceutical entity in September 1999 from the US market spurred considerable interest in the general safety and effectiveness of topical ophthalmic NSAIDs for treatment of anterior segment inflammation. In late 1999 the use of topical ocular NSAIDs declined in the US as a result of incidents involving corneal melts and toxicity surrounding use of generic diclofenac. However, since the removal of diclofenac sodium ophthalmic solution from the marketplace, ophthalmic NSAIDs have regained use as viable pharmacotherapeutic entities. Moreover, several new ophthalmic NSAID products have recently been introduced for commercial use in the US including the novel chemical entity nepafenac. The purpose of this report is to revisit the use of topical ophthalmic NSAIDs for the treatment of surgically induced anterior segment inflammation with a particular focus on nepafenac. Nepafenac is unique among ophthalmic NSAIDs in that it is a prodrug deaminated to amfenac, a highly effective non-selective cyclooxygenase inhibitor. In the case of topical ophthalmic NSAIDs, practitioners should carefully weigh the cost-benefit of implementing “highly potent” new drug products because perturbations in pharmacodynamic response due to the inherent novelty in terms of chemical designs may outweigh the demonstrated replicative pharmacologic action of all topical ophthalmic NSAIDs.

Management of Ocular Trauma in Emergency (MOTE) Trial: A pilot randomized double-blinded trial comparing topical amethocaine with saline in the outpatient management of corneal trauma

Background:

It is unclear whether local anesthetic eye drops can be safely used for the topical anesthesia of patients with minor corneal injury who are discharged from the emergency department (ED).

Objectives:

To assess whether topical 0.4% amethocaine self-administered to a maximum recommended frequency of once every hour for 36–48 h is safe in the management of uncomplicated corneal injury in patients discharged from the ED.

Patients and Methods:

A pilot randomized double-blinded trial comparing topical 0.4% amethocaine with topical normal saline.

Results:

Forty-seven subjects were recruited, with 22 randomized to receive amethocaine and 25 to receive placebo (normal saline). Baseline characteristics, including corneal injury type, were similar in both groups. There were no significant functional or clinical adverse sequelae in the majority of enrolled patients who could be contacted at 2 weeks (17/22 for amethocaine and 21/25 for placebo). Follow-up for the primary study outcome was suboptimal, with only 7/22 from the amethocaine group and 9/25 from the saline group presenting for 36–48 h review; there was a statistically nonsignificant trend for persistence of the corneal defect in the amethocaine group as compared with the saline group (2/7 and 1/9, respectively).

Conclusion:

Compared with saline drops, amethocaine eye drops are not definitely safe but they are effective for topical analgesia in minor corneal injury. Until further definitive studies, topical nonsteroidal agents or long-lasting artificial tears may be preferred for the topical analgesia of minor corneal injury. Return for corneal re-evaluation will necessarily remain suboptimal in an otherwise self-limiting condition, leading to a bias even if study recruitment is good.

Design and ocular tolerance of flurbiprofen loaded ultrasound-engineered NLC

Packaging small drug molecules, such as non-steroidal anti-inflammatory drugs (NSAIDs) into nanoparticulate systems has been reported as a promising approach to improve the drug's bioavailability, biocompatibility and safety profiles. In the last 20 years, lipid nanoparticles (lipid dispersions) entered the nanoparticulate library as novel carrier systems due to their great potential as an alternative to other systems such as polymeric nanoparticles and liposomes for several administration routes. For ocular instillation nanoparticulate carriers are required to have a low mean particle size, with the lowest polydispersity as possible. The purpose of this work was to study the combined influence of 2-level, 4-factor variables on the formulation of flurbiprofen (FB), a lipophilic NSAID, in lipid carriers currently named as nanostructured lipid carriers (NLC). NLC were produced with stearic acid (SA) and castor oil (CO) stabilized by Tween® 80 (non-ionic surfactant) in aqueous dispersion. A 2(4) full factorial design based on 4 independent variables was used to plan the experiments, namely, the percentage of SA with regard to the total lipid, the FB concentration, the stabilizer concentration, and the storage conditions (i.e., storage temperature). The effects of these parameters on the mean particle size, polydispersity index (PI) and zeta potential (ZP) were investigated as dependent variables. The optimization process was achieved and the best formulation corresponded to the NLC formulation composed of 0.05 (wt%) FB, 1.6 (wt%) Tween® 80 and a 50:50 ratio of SA to CO, with an average diameter of 288 nm, PI 0.245 of and ZP of -29 mV. This factorial design study has proven to be a useful tool in optimizing FB-loaded NLC formulations. Stability of the optimized NLC was predicted using a TurbiScanLab® and the ocular tolerance was assessed in vitro and in vivo by the Eytex® and Draize test, respectively. The developed systems were shown physico-chemically stable with high tolerance for eye instillation.

Efficacy and tolerability of preservative-free and preserved diclofenac and preserved ketorolac eyedrops after cataract surgery

PURPOSE

To compare the anti-inflammatory efficacy and subjective tolerability of preservative-free and preserved diclofenac 0.1% and preserved ketorolac 0.5% eye drops for prophylaxis and management of inflammation after cataract surgery.

DESIGN

Prospective, randomized, investigator-masked, parallel-group, comparative clinical trial.

METHODS

One hundred two patients who underwent small-incision phacoemulsification cataract surgery in an institutional setting were assigned randomly to receive preservative-free diclofenac sodium 0.1% (Voltaren ophtha SDU; Novartis Pharma), preserved diclofenac sodium 0.1% (Voltaren ophtha; Novartis Pharma), or preserved ketorolac tromethamine 0.5% (Acular; Pharm Allergan) eyedrops 4 times daily for 4 weeks after surgery. During the 1-month follow-up, anterior chamber flare and mean foveal thickness were evaluated for objective comparison of the anti-inflammatory effect. Ocular tolerability was assessed by observer-based grading of conjunctival hyperemia and ocular discomfort, as well as obtaining subjective ratings of ocular tolerability on a visual analog scale. Distance and near visual acuity and intraocular pressure served as safety measures.

RESULTS

All 3 formulations demonstrated equal anti-inflammatory efficacy as measured by reduction of anterior chamber flare after surgery and prevention of postoperative macular edema. Patients treated with preservative-free diclofenac eyedrops reported significantly better subjective tolerability values (P = .001), were classified as having less ocular discomfort (P < .001), and experienced earlier reduction of postoperative conjunctival hyperemia (P = .029).

CONCLUSIONS

Anti-inflammatory efficacy was comparable for all 3 agents. However, preservative-free diclofenac 0.1% eyedrops exhibited a significantly better postoperative subjective and objective tolerability when compared with preserved eyedrops containing ketorolac or diclofenac.