Topical indomethacin solution versus dexamethasone solution for treatment of inflamed pterygium and pinguecula: a prospective randomized clinical study

Corneal Healing and Recovery of Ocular Crystallinity with a Dichloromethane Extract of Sedum dendroideum D.C. in a Novel Murine Model of Ocular Pterygium

Pterygium is a corneal alteration that can cause visual impairment, which has been traditionally treated with the sap of Sedum dendroideum D.C. The pharmacological effect of a dichloromethane extract of S. dendroideum was demonstrated and implemented in a pterygium model on the healing process of corneal damage caused by phorbol esters. In mice of the ICR strain, a corneal lesion was caused by intravitreal injection of tetradecanoylphorbol acetate (TPA). The evolution of the corneal scarring process was monitored with vehicle, dexamethasone, and dichloromethane extract of S. dendroideum treatments by daily ophthalmic administration for fifteen days. The lesions were evaluated in situ with highlighted images of fluorescence of the lesions. Following treatment levels in eyeballs of IL-1α, TNF-α, and IL-10 cytokines were measured. The effective dose of TPA to produce a pterygium-like lesion was determined. The follow-up of the evolution of the scarring process allowed us to define that the treatment with S. dendroideum improved the experimental pterygium and had an immunomodulatory effect by decreasing TNF-α, IL-1α, and maintaining the level of IL-10 expression, without difference with respect to the healthy control. Traditional medical use of S. dendroideum sap to treat pterygium is fully justified by its compound composition.

The Key Role of VEGF in the Cross Talk between Pterygium and Dry Eye and Its Clinical Significance

PURPOSE

To examine whether dry eye severity is a risk factor for pterygium activity and whether vascular endothelial growth factor (VEGF) is crucial in the cross talk between pterygium and dry eye.

METHODS

A total of 103 patients with primary pterygium (Pteg) were included in the study group; they were divided into 2 groups according to the complication of dry eye (DE) (Pteg + DE group, Pteg - DE group). Further, 60 patients with just dry eye (DE group) and 60 normal individuals (normal) were included as 2 control groups. DE severity and pterygium activity were measured, and unstimulated tear samples and pterygium tissues were collected for cytokine detection.

RESULTS

(1) Tear detection: VEGF expression increased in the Pteg + DE group compared to the Pteg - DE, DE, and normal control groups; VEGF was especially increased in the active Pteg + DE group. VEGF concentration was positively correlated with pterygium activity. (2) Tissue detection: the mRNA expression of VEGF was upregulated in the active pterygium group.

CONCLUSIONS

Inflammation played an important role in the development of dry eye and pterygium. VEGF was the core molecule in the cross talk, which might explain the high incidence of the coexistence of these 2 diseases.

Clinical Features of Pingueculitis Revealed by Anterior Segment Optical Coherence Tomography Findings

PURPOSE

To investigate clinical features and treatment outcomes of pingueculitis with morphological assessments using anterior segment optical coherence tomography (AS-OCT).

METHODS

In this retrospective observational study, we examined 22 eyes of 22 patients with pingueculitis. All patients were treated with the same 2-week course of prednisolone acetate 1% drops four times per day. The clinical parameters evaluated were surface dimensions determined by slitlamp biomicroscopy, cross-sectional dimensions determined by AS-OCT, and symptom scores determined by patient surveys. Pretreatment and 1-month posttreatment values were compared with Wilcoxon signed-rank tests. Patients were followed up to 1 year after treatment.

RESULTS

Twenty-two eyes from 22 patients (4 men and 18 women) with an average age of 37.7±8.8 (range, 27-57) years and an average duration of symptoms of 22 (range, 5-60) days were included. The average follow-up period was 14.7±0.8 (range, 12-22) months. Mean pretreatment horizontal length, vertical length, conjunctival thickness, and cross-sectional area were 2.4±0.69 mm, 2.0±0.6 mm, 1.82±0.60 μm, and 5.14±2.05 mm, respectively. Mean posttreatment horizontal length, vertical length, conjunctival thickness, and area were 1.93±0.5 mm, 1.52±0.6 mm, 1.03±0.46 μm, and 2.33±0.83 mm, respectively. Mean pretreatment and posttreatment dry eye symptom scores were 3.27±0.77 and 1.13±0.38, respectively. The median pretreatment and posttreatment changes were statistically significant by Wilcoxon signed-rank tests for horizontal length (P<0.001), vertical length (P<0.001), conjunctival thickness (P=0.003), cross-sectional area (P=0.003), and dry eye symptom scores (P<0.001).

CONCLUSION

Anterior segment optical coherence tomography allows the quantification of differences in the pingueculitis measurements before and after treatment. In this retrospective study, a short course of topical steroids effectively treated the inflammation in a sustained manner. Anterior segment optical coherence tomography demonstrated significant reduction in the thickness and cross-sectional area of the pinguecula and a conversion back to a homogeneous conjunctival stroma.

Corneal Epithelial Damage and Impaired Tear Functions in Patients with Inflamed Pinguecula

Purpose

In this study, we evaluated corneal epithelial integrity and tear film parameters in patients with inflamed pinguecula and compared these findings with their fellow eyes and with healthy controls.

Methods

We evaluated the fluorescein staining properties and performed the tear break-up time (TBUT) test and Schirmer 2 test (ST2) measurements of 32 patients who had symptomatic unilateral inflamed pinguecula and compared the results with their fellow eyes and also with an age- and sex-matched control group.

Results

Twenty-three eyes (72%) in the inflamed pinguecula group and 1 eye (3.1%) in the fellow eyes group had punctate epithelial staining (PES) or epithelial defect on the nasal cornea (p < 0.001). There was no PES or epithelial defect in the control group. Eyes with inflamed pinguecula (n = 32) had lower TBUT and ST2 values compared to the control group (n = 32) (p < 0.001 for both). Fellow eyes (n = 32) also had lower TBUT and ST2 values compared to the control group (p=0.003 for both). There was no difference in the TBUT and ST2 results between the eyes with inflamed pinguecula and fellow eyes (p=0.286 and p=0.951, respectively).

Conclusion

A high percentage of eyes with inflamed pinguecula had nasal corneal epithelial staining or epithelial defect. We also found lower TBUT and ST2 results in eyes with inflamed pinguecula and the fellow eyes compared to the control group. These findings may be important in pathogenesis of pinguecula and pterygium and also in uncovering their relation.

Vascular Regression After Pinguecula Excision and Conjunctival Autograft Using Fibrin Glue

OBJECTIVES

To determine the change in local vascularization after pinguecula excision and conjunctival autograft secured with fibrin glue at 12 months.

METHODS

Thirty-one eyes of 31 patients which underwent excision and conjunctival autografting with fibrin glue were retrospectively reviewed. Anterior segment photography was obtained before and after the surgery. Cosmetic outcome was evaluated by patient self-grading (five-point scale; excellent (5), good (4), acceptable (3), poor (2), and very poor (1)), and medical evaluation of treatment outcome was based on subjective evaluation of vascularization on anterior segment photography (four-point severity scale; 0 [low] to 3 [high]). Clinical outcome and complications are reported at 12 months.

RESULTS

Overall cosmetic results were excellent or good in 93.5% (29 of 31) (score 4.68±0.60). Anterior segment photography showed that most cases demonstrated complete removal of pinguecula and regression of surrounding vascularization with mean change in score from 2.13±0.34 preoperatively to 0.09±0.30 postoperatively.

CONCLUSIONS

Pinguecula excision and conjunctival autograft using fibrin glue is an effective and safe method to remove pinguecula for cosmetic purposes. The method presented facilitated regression of vascularization.

Auto-avulsion and resolution of corneal pterygium

PURPOSE

Corneal pterygium is a frequently encountered ocular condition in clinical practice. The lesion presents as a fibrous, winged-like growth that typically manifests on the nasal aspect of the conjunctiva and cornea. Pterygia can be surgically removed by excision when they cause significant discomfort, visual impairment, or poor cosmesis. However, the recurrence rate after excision remains high without adjunctive therapy. We present an exceedingly rare case of resolution of a pterygium by auto-avulsion followed by subsequent recurrence of the lesion.

CASE REPORT

A 63-year-old Asian man presented to the clinic with pain and foreign body sensation. Anterior segment evaluation revealed a large corneal epithelial defect with an adjacent area of loose conjunctival tissue. Ocular history included a pterygium in the same area of the defect. Subsequent follow-up revealed a regrowth of the pterygium at the exact location.

CONCLUSIONS

Strong tension imposed on the cornea by a pterygium could result in auto-avulsion of the lesion. The resulting corneal defect can then be treated accordingly. Recurrent pterygium is possible without adjunctive therapy, such as those seen with bare sclera excision.

[Intra-lesional injection of betamethasone for the treatment of symptomatic pinguecula]

CLINICAL CASES

The pinguecula is a degenerative lesion which is usually asymptomatic, except when it is associated with an inflammatory reaction. We present 2 clinical cases of patients that had symptomatic pinguecula, in which intra-lesional betamethasone in depot form was used as treatment, obtaining a significant clinical improvement.

DISCUSSION

The administration of intra-lesional betamethasone in depot form may be a good alternative for the treatment of the symptomatic pinguecula.

Update on twice-daily bromfenac sodium sesquihydrate to treat postoperative ocular inflammation following cataract extraction

Ophthalmic bromfenac sodium sesquihydrate is a topically applied selective cyclooxygenase (COX)-2 inhibitor. It is similar to amfenac, except for a bromine atom at the C(4) of the benzoyl ring position, which markedly affects its in vitro and in vivo potency, extends the duration of anti-inflammatory activity, and enhances its inhibitory effect on COX-2 absorption across the cornea and penetration into ocular tissues. The United States Food and Drug Administration approved bromfenac in 2005 for the treatment of postoperative inflammation and the reduction of ocular pain in patients who have undergone cataract surgery. Nonsteroidal anti-inflammatory drugs (NSAIDs), and among them bromfenac, could be even more effective than steroids at reestablishing the blood-aqueous barrier, as revealed by flare on slit-lamp examination and as quantitatively measured using ocular fluorophotometry. Similar to other NSAIDs, it has a role in inhibiting intraoperative miosis during cataract surgery. However, bromfenac also seems to be useful in other situations, such as refractive surgery, allergic conjunctivitis (not useful in dry eye), choroidal neovascularization, and even ocular oncology. No reports of systemic toxicity have been published and bromfenac has good topical tolerance with a low incidence of adverse effects.

Nonsteroidal anti-inflammatory drugs in ophthalmology

Nonsteroidal anti-inflammatory drugs (NSAIDs) are increasingly employed in ophthalmology to reduce miosis and inflammation, manage scleritis, and prevent and treat cystoid macular edema associated with cataract surgery. In addition, they may decrease postoperative pain and photophobia associated with refractive surgery and may reduce the itching associated with allergic conjunctivitis. In recent years, the U.S. Food and Drug Administration has approved new topical NSAIDs, and previously approved NSAIDs have been reformulated. These additions and changes result in different pharmacokinetics and dosing intervals, which may offer therapeutic advantages. For example, therapeutic effects on diabetic retinopathy and age-related macular degeneration may now be achievable. We provide an updated review on NSAIDs and a summary of their current uses in ophthalmology with attention to potential future applications.

The presence of T-lymphocyte subpopulations (CD4 and CD8) in pterygia: evaluation of the inflammatory response

INTRODUCTION

The aim of our study was to confirm the presence of inflammatory T-lymphocyte subpopulations (CD4 and CD8) in pterygium specimens with regards to clinical severity. Additionally, we examined the effect of topical anti-inflammatory agents on the presence of T-lymphocyte subpopulations.

METHODS

Pterygia from nineteen eyes of nineteen patients who underwent surgical excision at Duke University, North Carolina, were included in this study. Normal conjunctiva from one patient was included as a control. Pterygia were pre-operatively graded as mild, moderate or severe based on objective signs of inflammation. Immunohistochemical staining for both CD4 and CD8 subpopulations of T lymphocytes was performed. Distribution of lymphocytes within the epithelium and substantia propria was graded by a masked observer on the following scale: 0 (none/rare), 1+ (mild), 2+ (moderate), or 3+ severe. Statistical analysis was performed using the Fisher exact test and Chi-square test.

RESULTS

A total of 16 (84%) pterygia specimens stained for T lymphocytes displayed approximately equal CD4 and CD8 infiltration of both the epithelium and the substantia propria. The majority of CD4 and CD8 lymphocytes were located in aggregates in the epithelium and upper substantia propria. The control specimen contained scant evidence of lymphocytic infiltration. There was no significant difference in the amount of lymphocytic infiltration between mild, moderate or severe pterygia. There was also no significant difference in lymphocytic infiltration between patients with (n=8) or without (n=11) a history of topical anti-inflammatory use.

CONCLUSION

The presence of CD4 and CD8 lymphocytes was confirmed in pterygia. There was no significant difference in lymphocytic infiltrate in patients with or without prior topical anti-inflammatory use. Based on these findings, topical immunomodulators may have an adjunctive role in the treatment of pterygia.

The role of NSAIDs in the management of postoperative ophthalmic inflammation

Recent advances in cataract surgery, such as phacoemulsification, small-incision surgery and advances in foldable intraocular lenses, have resulted in the decrease of physical trauma associated with cataract surgery. The decrease in the physical surgical trauma decreases the release of prostaglandins, which are the main players in postoperative ocular inflammation. However, postoperative inflammation continues to be a cause of patient discomfort, delayed recovery and, in some cases, suboptimal visual results. Left untreated, this inflammation might interfere with patients' rehabilitation and/or contribute to the development of other complications, such as cystoid macular oedema.NSAIDs are commercially available, in topical or systemic formulations, for the prophylaxis and treatment of ocular conditions. Topically applied NSAIDs are commonly used in the management and prevention of non-infectious ocular inflammation and cystoid macular oedema following cataract surgery. They are also used in the management of pain following refractive surgery and in the treatment of allergic conjunctivitis. Despite their chemical heterogeneity, all NSAIDs share the similar therapeutic property of inhibiting the cyclo-oxygenase enzyme. The appeal of using NSAIDs in the treatment of ocular inflammation hinges on the complications associated with corticosteroids, the other commonly used therapy for ophthalmic inflammation.

Toxic keratolysis from combined use of nonsteroid anti-inflammatory drugs and topical steroids following vitreoretinal surgery

PURPOSE

To evaluate the corneal complications associated with the combined use of non-steroid anti-inflammatory drugs (NSAIDs) and topical steroids following vitreoretinal surgery.

METHOD

Description of corneal lesions in three patients after vitrectomy with use of topical ketorolac and prednisolone acetate.

RESULTS

Three eyes of three patients developed an atrophic central corneal ulcer with stromal thinning following a pars plana vitrectomy under local anesthesia. Lesions were asymptomatic and were found during a routine examination 2, 3, and 8 weeks after surgery, respectively. Surgical indications were as follows: a preretinal membrane, choroidal neovascularization, and massive uveal effusion following cataract surgery. Topical postoperative treatment was as follows: ketorolac 4 times a day, a combination of prednisolone acetate, polymyxin B, and neomycin 6 times a day, and 1% cyclopentolate 3 times a day. Suspension of ketorolac and ocular occlusion led to the resolution of corneal lesions between 2.5 and 3 months later, yielding a central superficial scarring, which showed no changes after a follow-up of 3 years.

CONCLUSIONS

Toxic keratolysis may appear as a secondary effect of the combined use of topical NSAIDs and steroids following vitreo retinal surgery and must be taken into account in the differential diagnosis of postoperative corneal lesions.

Effects of the topical treatment with NSAIDs on corneal sensitivity and ocular surface of Sjögren's syndrome patients

AIM AND PURPOSE

To evaluate the effects of two NSAIDs on corneal sensitivity and ocular surface in Sjögren's syndrome (SS) patients.

METHODS

In all, 20 SS patients with epithelial corneal defects, were randomly divided into two groups: group 1 (10 females, age 35-63 years), treated with 0.1% indomethacin, one drop three times a day; group 2 (nine females, one male, age 38-65 years) treated with 0.1% diclofenac, at the same regimen. No systemic NSAIDs were allowed. Use of tear substitute was allowed. Corneal sensitivity, corneal staining, BUT, and ocular discomfort, were evaluated before and after 15, 30 days of treatment and 7 days after NSAID discontinuation. For statistical analysis, the Student's t-test and Mann-Whitney U test were used.

RESULTS

Both groups showed at day 30 a statistically significant reduction of corneal sensitivity (P<0.05), although the diclofenac-treated group showed a statistically significant lower sensitivity if compared to the indomethacin-treated group (P<0.05). Corneal fluorescein score showed a statistically significantly worst alteration in group 2, 7 days after the discontinuation of the therapy (P=0.02). The ocular discomfort score was statistically significantly reduced in both groups starting from day 15 (P<0.05).

DISCUSSION

The results indicate that NSAIDs can be useful in resolving symptoms of ocular discomfort in SS patients. However, they should be used with caution and under close monitoring, and the treatment should be promptly discontinued if corneal epithelial defects develop or worsen during treatment.

Comparison of Amniotic Membrane Graft Alone or Combined With Intraoperative Mitomycin C to Prevent Recurrence After Excision of Recurrent Pterygia

PURPOSE

Without effective adjunctive therapy, the recurrence rate after excision of recurrent pterygia is high. In an effort to determine a way to better reduce the recurrence of pterygia, we compared the efficacy and safety of amniotic membrane graft (AMG) alone and AMG combined with intraoperative mitomycin C after excision of recurrent pterygia.

METHODS

Patients with recurrent pterygia were randomly assigned to receive excision of pterygia followed by AMG alone or AMG combined with intraoperative 0.025% mitomycin C for 3 minutes (AMG-mitomycin C). Patients who could be followed up for more than 12 months were entered for data analysis. Conjunctival (potential) and corneal (true) recurrence of pterygia and other complications were recorded.

RESULTS

The group receiving AMG alone was made up of 48 eyes in 48 patients, and the group receiving AMG-mitomycin C consisted of 47 eyes in 46 patients. No significant difference was found in age distribution, sex distribution, or duration of follow-up between the 2 groups. Regarding the recurrence rates of each group, 6 conjunctival (12.5%) and 6 corneal (12.5%) recurrences developed in the AMG group, and 4 conjunctival (8.5%) and 6 corneal (12.8%) recurrences developed in the AMG-mitomycin C group. No significant difference was found in the conjunctival and corneal recurrence rate between the 2 groups (P=0.623 and 0.966, respectively; log rank test), and no major complications developed in either group.

CONCLUSIONS

AMG alone can be considered an effective alternative adjunctive treatment of recurrent pterygia. The addition of intraoperative mitomycin C did not further reduce the recurrence rate.

Is ophthalmology evidence based? A clinical audit of the emergency unit of a regional eye hospital

AIM

To evaluate the proportion of interventions that are evidence based in the acute care unit of a regional eye hospital.

METHODS

A prospective clinical audit was carried out at Hong Kong Eye Hospital in July 2002 to investigate the extent to which ophthalmic practices were evidence based. The major diagnosis and intervention provided were identified through chart review. A corresponding literature search using Medline and the Cochrane Library was performed to assess the degree to which each intervention was based on current, best evidence. Each diagnosis intervention pair was accordingly analysed and graded. The level of best, current evidence supporting each intervention was graded and analysed.

RESULTS

A total of 274 consecutive consultation episodes were examined. 22 cases were excluded since no diagnosis or intervention was made during the consultation. 108 (42.9%) patient interventions were found to be based on evidence from systematic reviews, meta-analyses, or randomised controlled trials (RCT). Evidence from prospective or retrospective observational studies supported the interventions in 86 (34.1%) patients. In 58 (23.0%) cases, no evidence or opposing evidence was found regarding the intervention. The proportion of evidence based on RCT or systematic reviews was higher for surgical interventions compared with non-surgical interventions (p=0.007). The proportion of interventions based on RCT or systematic reviews was higher for specialist ophthalmologists than trainee ophthalmologists (p=0.021).

CONCLUSION

This study demonstrated that the majority of interventions in the ophthalmic unit were evidence based and comparable to the experience of other specialties.

Topical nonsteroidal anti-inflammatory therapy in ophthalmology

Topically applied nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used in the management and prevention of ocular inflammation and cystoid macular edema related to cataract surgery and the maintenance of mydriasis during cataract surgery. Other common uses are the reduction of discomfort after refractive surgery or in allergic conjunctivitis. NSAIDs primarily act as cyclooxygenase inhibitors and thus reduce the formation of endogenous PGs. Today, several NSAIDs are commercially available: diclofenac, flurbiprofen, indomethacin, ketorolac and suprofen. At present the ophthalmologist has to make a decision between the use of topical corticosteroids, with their potential adverse effects, or of topical NSAIDs, with their possibly increased benefit, unknown effect on ocular pressure, wound healing and corneal tissue, higher costs and limited track record. However, the improvement of surgical techniques might support an increasing use of NSAIDs in the future. Preoperative anti-inflammatory treatment should be considered in eyes at a higher risk of developing severe postoperative inflammatory reactions. This decision has to be made carefully and has to be guided by the clinical circumstances, the spectrum of diagnosis and the individual benefit-risk ratio of each patient.

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

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used agents that despite chemically heterogeneity, share similar therapeutic properties and adverse effects. Topical ophthalmic NSAIDs are limited to the relatively water soluble phenylacetic and phenylalkanoic acids as well as indole derivatives, which are more suitable for ophthalmic use. Topical ophthalmic NSAIDs are commonly used in the treatment of post-operative inflammation following cataract extraction and various surgical refractive procedures. They are also used in the prevention and treatment of cystoid macular oedema and for the treatment of allergic conjunctivitis. Absorption of topical ophthalmic NSAIDs through the nasal mucosa results in systemic exposure and the occurrence of adverse systemic events, including exacerbation of bronchial asthma. Local irritant effects of topical ophthalmic NSAIDs include conjunctival hyperaemia, burning, stinging and corneal anaesthesia. A more serious complication involves the association of topical ophthalmic NSAIDs with indolent corneal ulceration and full-thickness corneal melts. Analysis of NSAID-associated corneal events implicates the now defunct generic dicolfenac product, diclofenac sodium ophthalmic solution as the agent primarily responsible. However, these events generated a renewed interest in the safety of ophthalmic NSAIDs and a scrutiny of the pharmacology regarding NSAID action in the eye. An elucidation of possible pharmacodynamic explanations of NSAID-induced corneal injury includes the role of epithelial hypoxia, which not only appears to aid in determining the metabolic destination of arachidonate, it may play a key role in orchestrating a novel inflammatory response unrelated to prostanoid formation. The use of NSAIDs under conditions of corneal hypoxia may therefore not only result in a disappointing therapeutic response, it may result in a paradoxical inflammatory exacerbation. Other potential mechanisms include the relationship between NSAIDs and corneal matrix metalloproteinase and direct toxicity due to cytotoxic excipients such as surfactants, solubilisers and preservatives found in topical NSAID ophthalmic preparations. In general, ophthalmic NSAIDs may be used safely with other ophthalmic pharmaceuticals; however, concurrent use of agents known to adversely effect the corneal epithelium, such as gentamicin, may lead to increased corneal penetration of the NSAID. The concurrent use of NSAIDs with topical corticosteorids in the face of significant pre-existing corneal inflammation has been identified as a risk factor in precipitating corneal erosions and melts and should be undertaken with caution. Until clinical evidence dictates otherwise, data supporting theories of potential pharmacodynamic mechanisms of NSAID injury do not alter the favorable benefit-risk ratio of ophthalmic NSAID use when employed in an appropriate and judicious manner.

Corneal complications associated with topical ophthalmic use of nonsteroidal antiinflammatory drugs

PURPOSE

To explore the potential association between adverse corneal events and the use of topical nonsteroidal antiinflammatory drugs (NSAIDs).

SETTING

Practice-based reports.

METHODS

A detailed case-reporting form and request for medical records were sent to all practices reporting cases of corneal or conjunctival pathology in association with the use of topical NSAIDs to the American Society of Cataract and Refractive Surgery. Cases were classified as "mild," "moderate," or "severe" according to predetermined clinical criteria.

RESULTS

Records of 140 eyes (129 patients) were reviewed; 51 cases (36.4%) were mild, 55 (39.3%) moderate, and 34 (24.3%) severe. An association with a specific topical NSAID was confirmed in 117 cases (81.8%). Most confirmed cases (53.8%) involved generic diclofenac (Falcon). Cases associated with brand diclofenac (Voltaren, CIBA Vision) and ketorolac (Acular, Allergan) were more likely to have ocular comorbidity and to have received significantly higher total doses of NSAIDs. Neither "off-label" use nor use of any specific agent was associated with severe compared to mild or moderate disease. However, patients with more severe adverse events were more likely to have a history of diabetes, previous surgery in the affected eye, and surgery other than cataract. Cases not occurring in the perioperative period had significantly worse outcomes, had significantly more ocular comorbidities, and received nearly 3 times the dose of NSAIDs.

CONCLUSIONS

While topical NSAIDs as a class may be associated with severe adverse events, such events appeared to require potentiation in the form of high total doses, ocular comorbidities, or both with Acular and Voltaren. Severe adverse events might have been more likely to occur at lower doses and in routine postoperative settings with generic diclofenac.