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Mian OT, Asif H, Sandhu U, Multani K, Farooq AV, Ding K, Riaz KM. Noninfectious Outcomes of Intravitreal Antibiotic Steroid Injection and Topical Nonsteroidal Antiinflammatory Drugs Versus Triple Drop Therapy After Cataract Surgery. Am J Ophthalmol 2024; 260:37-48. [PMID: 37944685 DOI: 10.1016/j.ajo.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 11/02/2023] [Accepted: 11/02/2023] [Indexed: 11/12/2023]
Abstract
PURPOSE To compare noninfectious outcomes of intravitreal antibiotic steroid (IVAS) injection (moxifloxacin-triamcinolone) and postoperative topical nonsteroidal antiinflammatory drugs (NSAID) with a standard 3-drop therapy (TDT) regimen (topical antibiotic, steroid, and NSAID) in patients after cataract surgery. DESIGN Retrospective comparative clinical cohort study. METHODS In 3 study centers in the United States, a total of 2143 eyes (N = 2143 patients) underwent cataract surgery with IVAS-NSAID or TDT between 2017 and 2022. Preoperative data were included, including patients' age, iris color, medical history, and ocular history. Postoperative data, including best-corrected visual acuity, intraocular pressure (IOP), and the need for IOP-lowering medications, were recorded at 1-week, 1-month, and 6-month time points. The primary outcome measures were postoperative complications, defined as persistent anterior chamber inflammation, persistent corneal edema (PCE), rebound inflammation, and cystoid macular edema, were compared between the 2 groups. RESULTS There were 1079 eyes in the IVAS-NSAID group and 1064 eyes in the TDT group. Best-corrected visual acuity and IOP were similar between IVAS-NSAID and TDT eyes at all time points. A portion (11.6%) of TDT eyes experienced postoperative complications compared with 6.5% in IVAS-NSAID eyes (P < .001). Femtosecond laser-assisted cataract surgery was associated with increased rates of PCE in IVAS-NSAID eyes, and eyes with dark irides had a higher incidence of cystoid macular edema, PCE, and rebound inflammation in the IVAS-NSAID group. CONCLUSION The IVAS-NSAID regimen overall had similar postoperative outcomes and fewer complications compared with the TDT regimen. IVAS-NSAID may be considered a safe alternative to topical regimens in non-femtosecond laser-assisted cataract surgery and patients with light irides.
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Affiliation(s)
- Osamah T Mian
- From the Department of Ophthalmology (O.T.M., K.M.R.), Dean McGee Eye Institute, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; College of Medicine (O.T.M., U.S., K.M., K.M.R.), University of Oklahoma, Oklahoma City, Oklahoma
| | - Hassaan Asif
- Department of Ophthalmology (H.A., A.V.F.), University of Chicago, Chicago, Illinois
| | - Umar Sandhu
- College of Medicine (O.T.M., U.S., K.M., K.M.R.), University of Oklahoma, Oklahoma City, Oklahoma
| | - Karan Multani
- College of Medicine (O.T.M., U.S., K.M., K.M.R.), University of Oklahoma, Oklahoma City, Oklahoma
| | - Asim V Farooq
- Department of Ophthalmology (H.A., A.V.F.), University of Chicago, Chicago, Illinois
| | - Kai Ding
- Department of Biostatistics and Epidemiology (K.D.), University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Kamran M Riaz
- From the Department of Ophthalmology (O.T.M., K.M.R.), Dean McGee Eye Institute, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; College of Medicine (O.T.M., U.S., K.M., K.M.R.), University of Oklahoma, Oklahoma City, Oklahoma.
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Ahmadzadeh A, Kessel L, Schmidt BS, Kolko M, Bach-Holm D. Steroids and/or Non-Steroidal Anti-Inflammatory Drugs as Postoperative Treatment after Trabeculectomy-12-Month Results of a Randomized Controlled Trial. J Clin Med 2024; 13:887. [PMID: 38337581 PMCID: PMC10856597 DOI: 10.3390/jcm13030887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 01/25/2024] [Accepted: 01/31/2024] [Indexed: 02/12/2024] Open
Abstract
This prospective randomized controlled trial aimed to compare the efficacy and safety of topical preservative-free diclofenac (DICLO) to dexamethasone (DEX) eyedrops, and their combination (DEX+DICLO) after trabeculectomy. Sixty-nine patients with medically uncontrolled glaucoma were randomized to receive topical postoperative treatment with DICLO (n = 23), DEX (n = 23), or a combination of DEX and DICLO (n = 23). The primary outcome was the intraocular pressure (IOP) 12 months postoperatively. Secondary outcomes included surgical success, failure, visual field, and visual acuity from baseline to 12 months postoperatively. IOP reached the lowest point one day after trabeculectomy. At 12 months, IOP was 10.0 mmHg (95% CI, 8.4-11.6 mmHg) for DICLO, 10.9 mmHg (95% CI, 9.4-12.3 mmHg) for DEX, and 11.2 mmHg (95% CI, 9.1-13.3 mmHg) for DEX+DICLO. There were no significant differences in IOP, surgical success, failure, visual field, or visual acuity between the DICLO, DEX, or DEX+DICLO groups. We found that topical diclofenac was not statistically different from topical dexamethasone in controlling IOP 12 months after trabeculectomy. Combining diclofenac and dexamethasone offered no added IOP control compared to dexamethasone alone.
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Affiliation(s)
- Afrouz Ahmadzadeh
- Department of Ophthalmology, Copenhagen University Hospital—Rigshospitalet, 2100 Copenhagen, Denmark
| | - Line Kessel
- Department of Ophthalmology, Copenhagen University Hospital—Rigshospitalet, 2100 Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, 2200 Copenhagen, Denmark
| | | | - Miriam Kolko
- Department of Ophthalmology, Copenhagen University Hospital—Rigshospitalet, 2100 Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, 2200 Copenhagen, Denmark
- Department of Drug Design and Pharmacology, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Daniella Bach-Holm
- Department of Ophthalmology, Copenhagen University Hospital—Rigshospitalet, 2100 Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, 2200 Copenhagen, Denmark
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Holland E, Karpecki P, Fingeret M, Schaeffer J, Gupta P, Fram N, Smits G, Ignacio T, Lindstrom R. Efficacy and Safety of CSF-1 (0.4% Pilocarpine Hydrochloride) in Presbyopia: Pooled Results of the NEAR Phase 3 Randomized, Clinical Trials. Clin Ther 2024; 46:104-113. [PMID: 38216351 DOI: 10.1016/j.clinthera.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 12/12/2023] [Accepted: 12/13/2023] [Indexed: 01/14/2024]
Abstract
PURPOSE This study was undertaken to evaluate the safety and efficacy of CSF-1 (0.4% pilocarpine hydrochloride ophthalmic solution) for use in individuals with presbyopia. METHODS Two Phase 3 multicenter, randomized, double-masked, vehicle-controlled, parallel-group clinical trials were conducted in 35 private ophthalmology clinics in the United States from October 2020 to February 2022. Key inclusion criteria were the following: (1) age 45-64 years, (2) distance-corrected near visual acuity (DCNVA) at 40 cm ≥0.40 and ≤0.90 logarithm of the minimum angle of resolution (logMAR, approximately 20/50-20/160 Snellen) in at least 1 eye, (3) manifest refraction (MR) between -4.50 and +2.00 diopter (D) sphere in each eye with ≤2.00D difference between eyes, (4) <2.00D of cylinder MR in each eye, (5) ≤0.04 logMAR (20/20-2 or better) corrected distance visual acuity (CDVA) at 4 m in each eye. Key exclusion criteria were the following: (1) >0.14 logMAR (7 letters) improvement in post-vehicle treatment in monocular DCNVA in either eye at visit 1, (2) introcular pressure (IOP) <9 or >22 mm Hg, (3) average dark-adapted pupillometry <3.5 mm in either eye, (4) prior refractive surgery or intraocular lens (IOL) implantation. Participants applied CSF-1 or vehicle twice per day for 2 weeks. Efficacy and safety assessments were performed at several times on days 1, 8, and 15. Response was defined as ≥3-line gain in DCNVA without loss of ≥1-line in CDVA in the study eye under mesopic room lighting conditions. The primary efficacy endpoint was measured 1 hour post-dose 1 on day 8. Key secondary endpoints were 2 hours post-dose 1, and 1 and 2 hours post-dose 2, also on day 8. Safety endpoints were ocular and non-ocular treatment-related adverse events (TRAE), conjunctival redness, drop comfort, slit-lamp biomicroscopy, intraocular pressure, indirect fundoscopy, and CDVA at 4 m. FINDINGS Six hundred thirteen participants were randomized to CSF-1 (n = 309) or vehicle (n = 304). Participants were predominantly White (80.8%) and female (62.0%), with mean age (standard deviation) of 54.7 (4.8). CSF-1 met the primary and key secondary endpoints. At the primary endpoint, 40.1% of the CSF-1 group achieved response versus 19.1% of the vehicle group (P < 0.0001). The percentage of responders was significantly greater in CSF-1 compared with vehicle at all tested times. Changes from baseline in all safety endpoints were comparable between groups. Most adverse events (AEs) were mild and transient. Neither serious nor severe AEs were reported with CSF-1. IMPLICATIONS CSF-1, a low-dose pilocarpine ophthalmic solution, demonstrated superiority to vehicle in improving near vision in individuals with presbyopia without compromising distance vision. CSF-1 demonstrated a favorable safety profile. CLINICALTRIALS gov identifier: NCT04599933 (NEAR-1), NCT04599972 (NEAR-2).
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Affiliation(s)
| | - Paul Karpecki
- The Kentucky College of Optometry, University of Pikeville, KY
| | - Murray Fingeret
- Department of Veterans Administration New York Harbor Health Care System, New York, NY
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You R, Han Y. A meta-analysis of topical Ketorolac's effect on surgical site wound healing post-cataract surgery. Int Wound J 2024; 21:e14661. [PMID: 38272819 PMCID: PMC10789915 DOI: 10.1111/iwj.14661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 12/24/2023] [Indexed: 01/27/2024] Open
Abstract
This meta-analysis evaluates the impact of topical ketorolac on surgical site wound healing and scar formation after cataract surgery. A thorough literature search, adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, identified eight relevant studies from 2348 articles. The selected studies were analysed for wound healing efficacy, using the redness, edema, ecchymosis, discharge and approximation (REEDA) scale, and scar formation, assessed by the Manchester scar scale (MSS). Results indicated that ketorolac significantly improved wound healing, with lower REEDA scores 1 week post-surgery (I2 = 97%; Random: standardised mean difference (SMD): -10.93, 95% CI: -13.85 to -8.00, p < 0.01), and reduced scar formation, evidenced by lower MSS scores 3 months post-surgery (I2 = 74%; Random: SMD: -9.67, 95% CI: -11.03 to -8.30, p < 0.01). The findings suggest that topical ketorolac is beneficial in post-cataract surgery care, enhancing wound healing and reducing scarring.
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Affiliation(s)
- Ran You
- Ophthalmology, Beijing Friendship HospitalCapital Medical UniversityBeijingChina
| | - Yu Han
- OphthalmologyBeijing Aier Eye HospitalBeijingChina
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5
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Heath M, McDonald MC, Murphy DA, Shah SV, Shah S, Ding K, Riaz KM. Fill levels, cost comparisons, and expulsion force requirements of commonly used topical ophthalmic nonsteroidal anti-inflammatory drugs. J Cataract Refract Surg 2023; 49:747-753. [PMID: 36853852 DOI: 10.1097/j.jcrs.0000000000001177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 02/21/2023] [Indexed: 03/01/2023]
Abstract
PURPOSE To determine volume fill levels, estimated costs, and force expulsion requirements per bottle of topical ophthalmic nonsteroidal anti-inflammatory drugs (NSAIDs) commonly perioperatively in the United States. SETTING Tertiary care academic medical center. DESIGN Prospective laboratory investigation. METHODS 8 commercially available NSAIDs (3 branded, 5 generic) were tested: branded bromfenac 0.07%, generic bromfenac 0.09%, diclofenac 0.1%, flurbiprofen 0.03%, generic ketorolac 0.5%, branded ketorolac 0.5%, ketorolac 0.47%, and branded nepafenac 0.3%. 10 bottles of each medication were tested, with an additional bottle tested for expulsion force requirements. A double-blinded method was used to measure the actual bottle fill volume and number of drops per bottle. The total cost per drop was calculated using published cash prices. Force requirements were measured using a customized force gauge apparatus. Formulations were compared using the Kruskal-Wallis test, followed by pairwise comparisons with the Dwass, Steel, Critchlow-Fligner Method. RESULTS 2 branded NSAIDs (bromfenac and nepafenac) had slightly lower-than-sticker volumes while generics other than ketorolac had higher-than-sticker volumes. Diclofenac and branded bromfenac had the highest and lowest adjusted number of drops respectively. Generic bromfenac and generic ketorolac had the highest and lowest adjusted volume compared with sticker volume respectively. Branded bromfenac was the most expensive medication, while generic diclofenac was the least expensive. Force expulsion requirements varied significantly among generic and branded NSAIDs. CONCLUSIONS Volume fill levels, patient-incurred costs, and expulsion force requirements per bottle of topical NSAID medications vary significantly. Surgeons may wish to consider these factors when deciding how best to use these medications perioperatively.
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Affiliation(s)
- Michael Heath
- From the Dean McGee Eye Institute, University of Oklahoma, Oklahoma City, Oklahoma (Heath, McDonald, Murphy, Riaz); Oklahoma School of Science and Mathematics, Oklahoma City, Oklahoma (S.V. Shah, S. Shah); Hudson College of Public Health, University of Oklahoma, Oklahoma City, Oklahoma (Ding)
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Ahmadzadeh A, Schmidt BS, Bach-Holm D, Kessel L. Early Inflammation Control After Trabeculectomy by Steroid and Non-steroidal Eye Drops: A Randomized Controlled Trial. Ophthalmol Ther 2023; 12:969-984. [PMID: 36602718 PMCID: PMC10011236 DOI: 10.1007/s40123-022-00636-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 12/06/2022] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION To compare the effect of three different anti-inflammatory regimens consisting of preservative-free dexamethasone (DEX), diclofenac (DICLO) eye drops, and their combination (DEX + DICLO) following trabeculectomy on early postoperative inflammation. METHODS A prospective randomized controlled trial. Sixty-nine patients undergoing trabeculectomy were randomized to receive either postoperative treatment with topical DEX (n = 23), topical DICLO (n = 23), or a combination of topical DEX and topical DICLO (n = 23) after trabeculectomy. The primary outcome was the anterior chamber flare measurement in the first 3 months postoperatively. Secondary outcomes included intraocular pressure, central corneal thickness, conjunctival injection, and number of cells in the anterior chamber from baseline to 3 months postoperatively. RESULTS Anterior chamber flare reached a maximum 1 day after trabeculectomy with an increase of 55% (95% CI 37-73%) for DEX, 64% (95% CI 47-82%) for DICLO, and 57% (95% CI 39-75%) for DEX + DICLO and returned to near pre-operative values 6 weeks after surgery. There were no significant differences in anterior chamber flare [effect size for DICLO: 0.16 (95% CI - 4.3 to 4.6), effect size for DEX + DICLO: 0.09 (95% CI - 4.1 to 4.3)], intraocular pressure, central corneal thickness, conjunctival injection, or number of cells in the anterior chamber between DEX, DICLO, or DEX + DICLO groups. CONCLUSION We found that topical diclofenac was not statistically different from topical dexamethasone in controlling early postoperative inflammation after trabeculectomy, while combining diclofenac and dexamethasone offered no added anti-inflammatory control compared to dexamethasone alone. TRIAL REGISTRATION www. CLINICALTRIALS gov (NCT04054830).
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Affiliation(s)
- Afrouz Ahmadzadeh
- Department of Ophthalmology, Copenhagen University Hospital-Rigshospitalet-Glostrup, Valdemar Hansens Vej 1-23, 2600, Glostrup, Denmark.
| | | | - Daniella Bach-Holm
- Department of Ophthalmology, Copenhagen University Hospital-Rigshospitalet-Glostrup, Valdemar Hansens Vej 1-23, 2600, Glostrup, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Line Kessel
- Department of Ophthalmology, Copenhagen University Hospital-Rigshospitalet-Glostrup, Valdemar Hansens Vej 1-23, 2600, Glostrup, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Way C, Swampillai AJ, Lim KS, Nanavaty MA. Factors influencing aqueous flare after cataract surgery and its evaluation with laser flare photometry. Ther Adv Ophthalmol 2023; 15:25158414231204111. [PMID: 38107248 PMCID: PMC10725112 DOI: 10.1177/25158414231204111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 09/11/2023] [Indexed: 12/19/2023] Open
Abstract
Despite the refinement of modern cataract surgery, postoperative inflammation still constitutes a substantial amount of visual morbidity worldwide. A surrogate for intraocular inflammation and blood-aqueous barrier breakdown can be objectively quantified by Laser flare photometry (LFP). This review outlines the utility of LFP in assessing the assessment of post-cataract surgery inflammation. It highlights the impact of preoperative pathological states such as uveitis and diabetes, intraoperative techniques, including efficient phacoemulsification and direct comparisons between postoperative anti-inflammatory regimes. There is a large interobserver variation in the subjective flare measurement after cataract surgery and the continued use of LFP amongst other objective, noninvasive measurements of intraocular inflammation, particularly in the further development of cataract surgery, is recommended.
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Affiliation(s)
- Christopher Way
- University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Andrew J. Swampillai
- Department of Ophthalmology, St. Thomas’ Hospital, London, UK
- School of Life Course & Population Sciences, King’s College London, London, UK
| | - Kin Sheng Lim
- Department of Ophthalmology, St. Thomas’ Hospital, London, UK
- School of Life Course & Population Sciences, King’s College London, London, UK
| | - Mayank A. Nanavaty
- University Hospitals Sussex NHS Foundation Trust, Sussex Eye Hospital, Eastern Road, Brighton, BN2 5BF, UK
- Brighton & Sussex Medical School, University of Sussex, Falmer, Brighton, UK
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Hansen NC, Erichsen JH, Holm LM, Kessel L. Corneal Thickness and Anterior Chamber Flare After Cataract Surgery: A Randomized Controlled Trial Comparing Five Regimens for Anti-Inflammatory Prophylaxis. Clin Ophthalmol 2021; 15:2835-2845. [PMID: 34234406 PMCID: PMC8254546 DOI: 10.2147/opth.s312350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 05/10/2021] [Indexed: 12/18/2022] Open
Abstract
Purpose To investigate the relationship between early post-operative anterior chamber inflammation (aqueous flare) and central corneal thickness (CCT) after cataract surgery and to evaluate the effect of anti-inflammatory prophylaxis on CCT. Setting Department of Ophthalmology, Rigshospitalet-Glostrup, University Hospital Copenhagen, Denmark. Design Post-hoc analysis of a prospective randomized controlled trial. Patients and Methods A total of 470 participants who underwent standard cataract surgery were randomly allocated to prophylactic treatment with nonsteroidal anti-inflammatory drug (NSAID, groups C and D) or a combination of NSAID and steroid eye drops (groups A and B), commenced either pre-operatively (A and C) or post-operatively on the day of surgery (B and D), or "drop-less surgery" (peri-operative subtenon depot of dexamethasone, group E). Aqueous flare was measured before and three days after surgery. CCT was measured before surgery, three days, three weeks, and three months after surgery. Data were analyzed according to the intention-to-treat method. Results Doubling of aqueous flare increased mean CCT by 15.6 microns (95% CI 9.8; 21.3, P<0.001) three days after surgery. Mean CCT increased from 549 microns (95% CI 545; 552) at baseline to 594 microns (95% CI 585; 602) three days after surgery and returned to 551 microns (95% CI 545; 557) three months after surgery. Mean CCT was thinner in group C compared to group A three days after surgery. No difference was found for any other groups or time points. Conclusion Increased anterior chamber inflammation was associated with significant corneal thickening three days after cataract surgery. Choice of anti-inflammatory regimen seemed to be of no or minimal importance on CCT when the effect of inflammation was accounted for. Corneal thickening is possibly mediated by underlying deterioration of the blood-aqueous barrier and corneal endothelium pump function caused by a post-operative inflammatory response.
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Affiliation(s)
| | | | - Lars Morten Holm
- Department of Ophthalmology, Rigshospitalet-Glostrup, Glostrup, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Line Kessel
- Department of Ophthalmology, Rigshospitalet-Glostrup, Glostrup, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Tripathi R, Balne PK, Sinha NR, Martin LM, Kamil S, Landreneau JR, Gupta S, Rodier JT, Sinha PR, Hesemann NP, Hofmann AC, Fink MK, Chaurasia SS, Mohan RR. A Novel Topical Ophthalmic Formulation to Mitigate Acute Mustard Gas Keratopathy In Vivo: A Pilot Study. Transl Vis Sci Technol 2020; 9:6. [PMID: 33200047 PMCID: PMC7645241 DOI: 10.1167/tvst.9.12.6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 09/09/2020] [Indexed: 01/29/2023] Open
Abstract
Purpose This pilot study investigated the in vivo therapeutic potential and tolerability of a multimodal ophthalmic formulation, topical eye drops (TED), for acute mustard gas keratopathy (MGK) using a rabbit model. Methods Twenty New Zealand White rabbits were used. Only right eyes of 18 rabbits (oculus dexter [OD]) received single sulfur mustard gas (SM) vapor injury, whereas contralateral eyes were left untreated or received TED for tolerabilty evaluation. Two rabbit eyes received no treatment and served as age-matched naive control. The four groups were: Naive (oculus sinister [OS] untreated eyes; n = 9); TED (OS treated only with TED BID for 3 days; n = 9); SM (OD exposed to SM vapor; n = 9); and SM+TED (OD exposed to SM+TED BID for 3 days; n = 9). Ocular examination in live rabbits were performed utilizing slit-lamp biomicroscopy, Fantes grading system, fluorescein staining, Schirmer's tests, pachymetry, and applanation tonometry. Cellular and molecular changes in rabbit corneas were assessed after humane euthanasia on day-3 and day-7 with histopathological and real-time polymerase chain reaction PCR techniques. Results TED to rabbit eyes was found tolerable in vivo. SM-exposed eyes showed significant increase in Fantes scores, central corneal thickness (CCT), Schirmer's test, epithelium-stroma separation, and corneal edema. TED mitigated clinical symptoms by reducing corneal edema, Fantes scores, CCT, and Schirmer's test. Further, TED decreased SM-induced corneal haze, inflammatory and profibrotic markers, transforming growth factor-TGF-β1 and cyclooxygenase-2COX-2, and damage to corneal structure, including epithelial-stromal integrity. Conclusions The developed multimodal eyedrop formulation, TED, has potential to mitigate acute MGK effectively in vivo. Translational Relevance TED is effective against MGK.
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Affiliation(s)
- Ratnakar Tripathi
- Harry S. Truman Memorial Veterans’ Hospital, Columbia, MO, USA
- One-Health Vision Research Program, Departments of Veterinary Medicine and Surgery and Biomedical Sciences, College of Veterinary Medicine, University of Missouri, Columbia, MO, USA
| | - Praveen K. Balne
- Harry S. Truman Memorial Veterans’ Hospital, Columbia, MO, USA
- One-Health Vision Research Program, Departments of Veterinary Medicine and Surgery and Biomedical Sciences, College of Veterinary Medicine, University of Missouri, Columbia, MO, USA
| | - Nishant R. Sinha
- Harry S. Truman Memorial Veterans’ Hospital, Columbia, MO, USA
- One-Health Vision Research Program, Departments of Veterinary Medicine and Surgery and Biomedical Sciences, College of Veterinary Medicine, University of Missouri, Columbia, MO, USA
| | - Lynn M. Martin
- Harry S. Truman Memorial Veterans’ Hospital, Columbia, MO, USA
- One-Health Vision Research Program, Departments of Veterinary Medicine and Surgery and Biomedical Sciences, College of Veterinary Medicine, University of Missouri, Columbia, MO, USA
| | - Sabeeh Kamil
- Harry S. Truman Memorial Veterans’ Hospital, Columbia, MO, USA
- One-Health Vision Research Program, Departments of Veterinary Medicine and Surgery and Biomedical Sciences, College of Veterinary Medicine, University of Missouri, Columbia, MO, USA
| | - James R. Landreneau
- Harry S. Truman Memorial Veterans’ Hospital, Columbia, MO, USA
- Mason Eye Institute, School of Medicine, University of Missouri, Columbia, MO, USA
| | - Suneel Gupta
- Harry S. Truman Memorial Veterans’ Hospital, Columbia, MO, USA
- One-Health Vision Research Program, Departments of Veterinary Medicine and Surgery and Biomedical Sciences, College of Veterinary Medicine, University of Missouri, Columbia, MO, USA
| | - Jason T. Rodier
- Harry S. Truman Memorial Veterans’ Hospital, Columbia, MO, USA
- Mason Eye Institute, School of Medicine, University of Missouri, Columbia, MO, USA
| | - Prashant R. Sinha
- Harry S. Truman Memorial Veterans’ Hospital, Columbia, MO, USA
- One-Health Vision Research Program, Departments of Veterinary Medicine and Surgery and Biomedical Sciences, College of Veterinary Medicine, University of Missouri, Columbia, MO, USA
| | - Nathan P. Hesemann
- Harry S. Truman Memorial Veterans’ Hospital, Columbia, MO, USA
- Mason Eye Institute, School of Medicine, University of Missouri, Columbia, MO, USA
| | - Alexandria C. Hofmann
- One-Health Vision Research Program, Departments of Veterinary Medicine and Surgery and Biomedical Sciences, College of Veterinary Medicine, University of Missouri, Columbia, MO, USA
- Mason Eye Institute, School of Medicine, University of Missouri, Columbia, MO, USA
| | - Michael K. Fink
- Harry S. Truman Memorial Veterans’ Hospital, Columbia, MO, USA
- One-Health Vision Research Program, Departments of Veterinary Medicine and Surgery and Biomedical Sciences, College of Veterinary Medicine, University of Missouri, Columbia, MO, USA
| | - Shyam S. Chaurasia
- Harry S. Truman Memorial Veterans’ Hospital, Columbia, MO, USA
- One-Health Vision Research Program, Departments of Veterinary Medicine and Surgery and Biomedical Sciences, College of Veterinary Medicine, University of Missouri, Columbia, MO, USA
| | - Rajiv R. Mohan
- Harry S. Truman Memorial Veterans’ Hospital, Columbia, MO, USA
- One-Health Vision Research Program, Departments of Veterinary Medicine and Surgery and Biomedical Sciences, College of Veterinary Medicine, University of Missouri, Columbia, MO, USA
- Mason Eye Institute, School of Medicine, University of Missouri, Columbia, MO, USA
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Cagini C, Pellegrino A, Cerquaglia A, Iaccheri B, Lupidi M, Fiore T. Comparison of the Effect of Diclofenac 0.1% and Nepafenac 0.1% on Aqueous Flare in Patients Undergoing Cataract Surgery: A Prospective Randomized Study. Curr Eye Res 2020; 45:1089-1093. [DOI: 10.1080/02713683.2020.1725061] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Carlo Cagini
- Department of Biomedical and Surgical Sciences, Ophthalmology Section, University of Perugia, Perugia, Italy
| | - Adriana Pellegrino
- Department of Biomedical and Surgical Sciences, Ophthalmology Section, University of Perugia, Perugia, Italy
| | - Alessio Cerquaglia
- Department of Biomedical and Surgical Sciences, Ophthalmology Section, University of Perugia, Perugia, Italy
| | - Barbara Iaccheri
- Department of Biomedical and Surgical Sciences, Ophthalmology Section, University of Perugia, Perugia, Italy
| | - Marco Lupidi
- Department of Biomedical and Surgical Sciences, Ophthalmology Section, University of Perugia, Perugia, Italy
| | - Tito Fiore
- Department of Biomedical and Surgical Sciences, Ophthalmology Section, University of Perugia, Perugia, Italy
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Rigas B, Huang W, Honkanen R. NSAID-induced corneal melt: Clinical importance, pathogenesis, and risk mitigation. Surv Ophthalmol 2020; 65:1-11. [DOI: 10.1016/j.survophthal.2019.07.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 07/01/2019] [Accepted: 07/02/2019] [Indexed: 12/21/2022]
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Ylinen P, Taipale C, Lindholm JM, Laine I, Holmström E, Tuuminen R. Postoperative management in cataract surgery: nepafenac and preservative-free diclofenac compared. Acta Ophthalmol 2018; 96:853-859. [PMID: 30284393 DOI: 10.1111/aos.13843] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 05/14/2018] [Indexed: 12/19/2022]
Abstract
PURPOSE Current cataract surgery guidelines recommend routine use of topical nonsteroidal anti-inflammatory drugs (NSAIDs) in preventing pseudophakic cystoid macular oedema (PCME). Here, we compare the clinical efficacy and tolerability of two potent NSAIDs, nepafenac and preservative-free diclofenac following cataract surgery. METHODS Randomized, double-blind, prospective single-centre study. Ninety-six eyes of 95 patients undergoing routine cataract surgery were randomized 1:1 either to nepafenac (Nevanac, 1 mg/ml) or diclofenac (Dicloabak, 1 mg/ml) for 3 weeks. Seventy-three patients accounting for 73 eyes completed the entire follow-up. Aqueous flare and central retinal thickness (CRT) analysis were conducted preoperatively and at control visits 28 days and 3 months after surgery. A structured home questionnaire and interview were used to record any adverse effects of the topical medications, subjective visual recovery and the dispenser's ease of use. RESULTS No differences were observed between the groups for aqueous flare, CRT, speed of recovery or visual acuity gain. Seven patients (16%) on nepafenac and 20 patients (48%) on preservative-free diclofenac reported symptoms related to topical use of NSAID medications (p = 0.001). CONCLUSION No differences in clinical efficacy were found between potent NSAIDs, while tolerability might be an issue.
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Affiliation(s)
- Petteri Ylinen
- Helsinki Retina Research Group; University of Helsinki; Helsinki Finland
- Department of Ophthalmology; Helsinki University Hospital; Helsinki Finland
| | - Claudia Taipale
- Helsinki Retina Research Group; University of Helsinki; Helsinki Finland
- Department of Ophthalmology; Helsinki University Hospital; Helsinki Finland
| | - Juha-Matti Lindholm
- Helsinki Retina Research Group; University of Helsinki; Helsinki Finland
- Department of Ophthalmology; Helsinki University Hospital; Helsinki Finland
| | - Ilkka Laine
- Helsinki Retina Research Group; University of Helsinki; Helsinki Finland
- Department of Automation and Electrical Engineering; Aalto University; Helsinki Finland
| | - Emil Holmström
- Helsinki Retina Research Group; University of Helsinki; Helsinki Finland
- Transplantation Laboratory; University of Helsinki; Helsinki Finland
| | - Raimo Tuuminen
- Helsinki Retina Research Group; University of Helsinki; Helsinki Finland
- Unit of Ophthalmology; Kymenlaakso Central Hospital; Kotka Finland
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Bodaghi B, Weber ME, Arnoux YV, Jaulerry SD, Le Hoang P, Colin J. Comparison of the Efficacy and Safety of two Formulations of Diclofenac Sodium 0.1 % Eyedrops in Controlling Postoperative Inflammation after Cataract Surgery. Eur J Ophthalmol 2018; 15:702-11. [PMID: 16329054 DOI: 10.1177/112067210501500608] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To compare the efficacy and safety of diclofenac sodium 0.1% eyedrops packaged in an Abak multidose container without preservative (Dicloabak) with the reference product, sodium merthiolate-preserved diclofenac sodium 0.1% eyedrops, in controlling postoperative inflammation after cataract surgery. METHODS The multicenter, controlled, randomized, single-masked study included 194 patients (Dicloabak 96, preserved diclofenac 98) scheduled to have cataract surgery by phacoemulsification with foldable intraocular lens. All were evaluated preoperatively and postoperatively after 1, 7, and 28 days. Postoperative inflammation was measured by the total score of anterior chamber cells and flare. Ocular plin, conjunctival hyperemia and ciliary flush were also assessed. Postoperative patient assessments also included visual acuity, objective tolerance by slit-lamp, fluorescein test, and subjective evaluation of local tolerance. RESULTS There was no statistically significant difference between the groups in the total score of flare and cells or the degree of conjunctival hyperemia and ciliary flush at any study visit. Dicloabak was demonstrated to be not inferior to preserved diclofenac at all assessment times. The overall assessment of local tolerance was similar for both study medications. CONCLUSIONS Preservative suppression did not alter diclofenac efficacy. Results support the good safety profile of both formulations when dosed three times daily for 4 weeks in absence of concomitant use of drugs potentially toxic for cornea. Preservative-free formulations like Dicloabak should be preferred to generic diclofenac formulations including other ingredients and may improve the safety profile of this topical nonsteroid anti-inflammatory drug.
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Affiliation(s)
- B Bodaghi
- Service d'Ophtalmologie, Hôpital Pitié-Salpétrière, Paris, France.
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The comparative efficacy and safety of topical non-steroidal anti-inflammatory drugs for the treatment of anterior chamber inflammation after cataract surgery: a systematic review and network meta-analysis. Graefes Arch Clin Exp Ophthalmol 2017; 255:639-649. [DOI: 10.1007/s00417-017-3599-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 01/11/2017] [Accepted: 01/17/2017] [Indexed: 01/01/2023] Open
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Wilson DJ, Schutte SM, Abel SR. Comparing the Efficacy of Ophthalmic NSAIDs in Common Indications. Ann Pharmacother 2015; 49:727-34. [PMID: 25725037 DOI: 10.1177/1060028015574593] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: To review the commercially available ophthalmic nonsteroidal anti-inflammatory drugs (NSAIDs), identify opportunities for therapeutic substitutions within and outside of their Food and Drug Administration (FDA)-approved indications, and identify clinically superior drugs within the class for specific indications. Data Source: A PubMed search (1992 through January 2014) was performed on the terms diclofenac, ketorolac, flurbiprofen, bromfenac, and nepafenac. Study Selection and Data Extraction: Clinical trials, meta-analyses, and review articles were evaluated if they were written in English and pertained to human subjects. Studies were excluded if they were in vitro studies, solely evaluated pharmacokinetic or pharmacodynamic properties, did not relate to the topical ophthalmic route, did not evaluate the FDA-approved indications of any available ophthalmic NSAID, or compared a reviewed drug with a nonreviewed drug (without placebo comparison). Data Synthesis: A total of 67 articles met the criteria for evaluation. Article quality, study design, and dosing of the medications were assessed to determine the clinical applicability of the results. The quality of the article was determined using the Oxford Centre for Evidence-based Medicine Levels of Evidence 1. Conclusions: Many formulations of the 5 reviewed NSAIDs have been studied across the 4 primary indications. These indications are (1) pain and inflammation associated with cataract surgery, (2) pain associated with corneal refractive surgery, (3) inhibition of intraoperative miosis, and (4) seasonal allergic conjunctivitis. Several studies have directly compared drugs within this class and have identified instances in which certain selections are therapeutically superior or equivalent to another. This information provides practitioners with guidance in selecting an optimal medication.
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Affiliation(s)
| | | | - Steven R. Abel
- Purdue University College of Pharmacy, West Lafayette, IN, USA
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Tzelikis PF, Vieira M, Hida WT, Motta AF, Nakano CT, Nakano EM, Alves MR. Comparison of ketorolac 0.4% and nepafenac 0.1% for the prevention of cystoid macular oedema after phacoemulsification: prospective placebo-controlled randomised study. Br J Ophthalmol 2014; 99:654-8. [PMID: 25385061 DOI: 10.1136/bjophthalmol-2014-305803] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 10/22/2014] [Indexed: 01/29/2023]
Abstract
PURPOSE To compare the anti-inflammatory efficacy of ketorolac of tromethamine 0.4% and nepafenac 0.1% eye drops for prophylaxis of cystoid macular oedema (CME) after small-incision cataract extraction. METHODS Patients were assigned randomly to three groups. Group 1 patients received a topical artificial tear substitute (placebo); group 2 received ketorolac tromethamine 0.4% (Acular LS, Allergan) and group 3 received nepafenac 0.1% (Nevanac, Alcon). The incidence and severity of CME were evaluated by retinal foveal thickness on optical coherence tomography (OCT) after 1, 4 and 12 weeks. RESULTS One hundred and twenty-six eyes of 126 patients were included in this study. The between-group differences in visual outcomes, central corneal thickness and endothelial cell density were not statistically significant. In all retinal thickness measurements, an increase was detected starting from the postoperative first week until 12 weeks. There was no statistically significant difference between the three groups in any measurement performed by spectral-domain OCT. CONCLUSIONS Used prophylactically after uneventful cataract surgery, non-steroidal anti-inflammatory drugs were not efficacious in preventing macular oedema compared with placebo. TRIAL REGISTRATION NUMBER ClinicalTrials: NCT02084576.
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Affiliation(s)
| | - Monike Vieira
- Brasilia Ophthalmologic Hospital, HOB, Brasilia, DF, Brazil
| | - Wilson Takashi Hida
- Brasilia Ophthalmologic Hospital, HOB, Brasilia, DF, Brazil Ophthalmology Department, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Antonio Francisco Motta
- Ophthalmology Department, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Celso Takashi Nakano
- Ophthalmology Department, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - Milton Ruiz Alves
- Ophthalmology Department, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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Grob SR, Gonzalez-Gonzalez LA, Daly MK. Management of mydriasis and pain in cataract and intraocular lens surgery: review of current medications and future directions. Clin Ophthalmol 2014; 8:1281-9. [PMID: 25061276 PMCID: PMC4086849 DOI: 10.2147/opth.s47569] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The maintenance of mydriasis and the control of postoperative pain and inflammation are critical to the safety and success of cataract and intraocular lens replacement surgery. Appropriate mydriasis is usually achieved by topical and/or intracameral administration of anticholinergic agents, sympathomimetic agents, or both, with the most commonly used being cyclopentolate, tropicamide, and phenylephrine. Ocular inflammation is common after cataract surgery. Topical steroids and nonsteroidal anti-inflammatory drugs are widely used because they have been proved effective to control postsurgical inflammation and decrease pain. Topical nonsteroidal anti-inflammatory drugs have also been shown to help maintain dilation. However, use of multiple preoperative drops for pupil dilation, inflammation, and pain control have been shown to be time consuming, resulting in delays to the operating room, and they cause dissatisfaction among perioperative personnel; their use can also be associated with systemic side effects. Therefore, ophthalmologists have been in search of new options to streamline this process. This article will review the current medications commonly used for intraoperative mydriasis, as well as pain and inflammation control. In addition, a new combination of ketorolac, an anti-inflammatory agent, and phenylephrine, a mydriatic agent has recently been designed to maintain intraoperative mydriasis and to reduce postoperative pain and irritation from intraocular lens replacement surgery. Two Phase III clinical trials evaluating this combination have demonstrated statistically significant differences when compared to placebo in maintaining intraoperative mydriasis (P<0.00001) and in reducing pain in the early postoperative period (P=0.0002). This medication may be of benefit for use in cataract and lens replacement surgery in the near future.
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Affiliation(s)
- Seanna R Grob
- Department of Ophthalmology, Veterans Administration Boston Healthcare System, Boston, MA, USA ; Department of Ophthalmology, Harvard Medical School, Boston, MA, USA ; Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Luis A Gonzalez-Gonzalez
- Department of Ophthalmology, Veterans Administration Boston Healthcare System, Boston, MA, USA ; Department of Ophthalmology, Harvard Medical School, Boston, MA, USA ; Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Mary K Daly
- Department of Ophthalmology, Veterans Administration Boston Healthcare System, Boston, MA, USA ; Department of Ophthalmology, Harvard Medical School, Boston, MA, USA ; Department of Ophthalmology, Boston University School of Medicine, Boston, MA, USA
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Post-cataract prevention of inflammation and macular edema by steroid and nonsteroidal anti-inflammatory eye drops: a systematic review. Ophthalmology 2014; 121:1915-24. [PMID: 24935281 DOI: 10.1016/j.ophtha.2014.04.035] [Citation(s) in RCA: 180] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Revised: 04/01/2014] [Accepted: 04/23/2014] [Indexed: 12/18/2022] Open
Abstract
PURPOSE Favorable outcome after cataract surgery depends on proper control of the inflammatory response induced by cataract surgery. Pseudophakic cystoid macular edema is an important cause of visual decline after uncomplicated cataract surgery. DESIGN We compared the efficacy of topical steroids with topical nonsteroidal anti-inflammatory drugs (NSAIDs) in controlling inflammation and preventing pseudophakic cystoid macular edema (PCME) after uncomplicated cataract surgery. PARTICIPANTS Patients undergoing uncomplicated surgery for age-related cataract. METHODS We performed a systematic literature search in Medline, CINAHL, Cochrane, and EMBASE databases to identify randomized trials published from 1996 onward comparing topical steroids with topical NSAIDs in controlling inflammation and preventing PCME in patients undergoing phacoemulsification with posterior chamber intraocular lens implantation for age-related cataract. MAIN OUTCOME MEASURES Postoperative inflammation and pseudophakic cystoid macular edema. RESULTS Fifteen randomized trials were identified. Postoperative inflammation was less in patients randomized to NSAIDs. The prevalence of PCME was significantly higher in the steroid group than in the NSAID group: 3.8% versus 25.3% of patients, risk ratio 5.35 (95% confidence interval, 2.94-9.76). There was no statistically significant difference in the number of adverse events in the 2 treatment groups. CONCLUSIONS We found low to moderate quality of evidence that topical NSAIDs are more effective in controlling postoperative inflammation after cataract surgery. We found high-quality evidence that topical NSAIDs are more effective than topical steroids in preventing PCME. The use of topical NSAIDs was not associated with an increased events. We recommend using topical NSAIDs to prevent inflammation and PCME after routine cataract surgery.
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Bodaghi B. Diclofenac sodium 0.1% ophthalmic solution: update on pharmacodynamics, clinical interest and safety profile. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/17469899.3.2.139] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Prophylactic nepafenac and ketorolac versus placebo in preventing postoperative macular edema after uneventful phacoemulsification. J Cataract Refract Surg 2012; 38:1537-43. [PMID: 22795976 DOI: 10.1016/j.jcrs.2012.04.034] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Revised: 04/19/2012] [Accepted: 04/27/2012] [Indexed: 11/22/2022]
Abstract
PURPOSE To evaluate the efficacy of prophylactic ketorolac 0.5% versus nepafenac 0.1% versus placebo on macular volume 1 month after uneventful phacoemulsification and evaluate the health-related quality-of-life (HRQOL) of topical nonsteroidal antiinflammatory drugs (NSAIDs) in the context of cataract surgery. SETTING Hotel Dieu Hospital, Kingston, Ontario, Canada. DESIGN Prospective placebo-controlled parallel-assignment double-masked randomized clinical trial. METHODS In this study, patients 18 years or older scheduled for routine phacoemulsification were randomized to a placebo, ketorolac 0.5%, or nepafenac 0.1% and dosed 4 times a day starting 1 day before surgery and continuing for 4 weeks. Spectral-domain macular cube ocular coherence tomography scans measuring central subfield thickness, macular cube volume, and average macular cube thickness were performed at baseline and 1 month postoperatively. The HRQOL metrics were determined with the Comparison of Ophthalmic Medications for Tolerability (COMTOL) questionnaire. RESULTS Each study group comprised 54 patients. One month postoperatively, although a trend toward significance occurred for nepafenac and ketorolac, analysis of the means of differences showed no statistically significant differences between the 3 study groups (P=.2901). The COMTOL analysis found no difference in tolerability, compliance, side-effect frequency and bother, and effects on HRQOL between ketorolac and nepafenac compared with the placebo. CONCLUSIONS One month after uneventful phacoemulsification, there was no difference in macular volume between the placebo, ketorolac, and nepafenac. Ketorolac and nepafenac were well tolerated with minimal side-effect profiles. Thus, for patients without risk factors having routine surgery, prophylactic topical NSAIDs are not recommended.
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Abstract
Ketorolac 0.45% ophthalmic solution is a topical NSAID indicated in the US for the treatment of ocular pain and inflammation following cataract surgery. In animal studies, the ocular relative bioavailability of single-dose topical ketorolac 0.45% ophthalmic solution was 2- to 3-fold higher than that of ketorolac 0.4% ophthalmic solution. In two identically designed, randomized, double-masked, multicentre trials in adult patients undergoing cataract extraction, the proportions of patients with a summed ocular inflammation score of zero for anterior chamber cell count plus anterior chamber flare on day 14 after surgery were significantly greater in those treated with topical ketorolac 0.45% ophthalmic solution than in those treated with vehicle placebo. Compared with placebo, topical ketorolac 0.45% ophthalmic solution significantly increased the proportion of patients who were pain-free on the day after surgery in both trials. Ketorolac 0.45% ophthalmic solution was generally well tolerated in clinical trials with lower overall incidences of treatment-emergent and treatment-related adverse events than placebo, and with no single treatment-related adverse event having a higher incidence than with placebo.
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Toris CB, Gulati V. The biology, pathology and therapeutic use of prostaglandins in the eye. ACTA ACUST UNITED AC 2011. [DOI: 10.2217/clp.11.42] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Maca SM, Amon M, Findl O, Kahraman G, Barisani-Asenbauer T. Efficacy and tolerability of preservative-free and preserved diclofenac and preserved ketorolac eyedrops after cataract surgery. Am J Ophthalmol 2010; 149:777-84. [PMID: 20152959 DOI: 10.1016/j.ajo.2009.12.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2009] [Revised: 12/01/2009] [Accepted: 12/04/2009] [Indexed: 10/19/2022]
Abstract
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.
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Kim SJ, Flach AJ, Jampol LM. Nonsteroidal anti-inflammatory drugs in ophthalmology. Surv Ophthalmol 2010; 55:108-33. [PMID: 20159228 DOI: 10.1016/j.survophthal.2009.07.005] [Citation(s) in RCA: 240] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2009] [Revised: 07/20/2009] [Accepted: 07/28/2009] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Stephen J Kim
- Department of Ophthalmology, Vanderbilt University, Nashville, Tennessee 37232, USA.
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Cervantes-Coste G, Sánchez-Castro YG, Orozco-Carroll M, Mendoza-Schuster E, Velasco-Barona C. Inhibition of surgically induced miosis and prevention of postoperative macular edema with nepafenac. Clin Ophthalmol 2009; 3:219-26. [PMID: 19668569 PMCID: PMC2708994 DOI: 10.2147/opth.s4820] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective: To evaluate the effectiveness of prophylactic administration of nepafenac 0.1% in maintaining mydriasis and in preventing postoperative macular edema following cataract surgery. Methods: This was a prospective, randomized, single-masked comparative study in 60 patients undergoing phacoemulsification cataract surgery. Patients were randomized to either the nepafenac or the control group. Nepafenac was administered 3 times daily 1 day before surgery and continued for 6 weeks. The control group received tobramycin-dexamethasone treatment only. Trans-operative mydriasis was measured before surgery, after nuclear emulsification, following cortex aspiration, and at the conclusion of surgery. Macular optical coherence tomography determined central foveal thickness (FT) and total macular volume (TMV) before surgery and at 2 and 6 weeks after surgery. All patients received tobramycin-dexamethasone for 2 weeks after surgery. Results: The difference in mean pupil size, at the end of surgery, between the control group (6.84 ± 0.93 mm) and the nepafenac group (7.91 ± 0.74 mm) was statistically significant (p < 0.001). There were no significant differences in FT values between the two groups at any time point; however, TMV at 2 and at 6 weeks was statistically significantly different (p < 0.001), with higher TMV in the control group. Conclusion: Prophylactic use of nepafenac was effective in reducing macular edema after cataract surgery and in maintaining trans-operative mydriasis.
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Affiliation(s)
- Guadalupe Cervantes-Coste
- Asociación Para Evitar la Ceguera en México I.A.P. Hospital "Dr Luis Sánchez Bulnes", México City, México
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Patidar N, Rathore MS, Sharma DK, Middha A, Gupta VB. Transcorneal permeation of ciprofloxacin and diclofenac from marketed eye drops. Indian J Pharm Sci 2008; 70:651-4. [PMID: 21394267 PMCID: PMC3038295 DOI: 10.4103/0250-474x.45409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2006] [Revised: 03/03/2008] [Accepted: 10/08/2008] [Indexed: 11/04/2022] Open
Abstract
The purpose of this research was to evaluate the in vitro permeation characteristics of various marketed eye drops of ciprofloxacin (0.3% w/v aqueous solution) and diclofenac (0.1% w/v aqueous solution) through isolated goat cornea. Effect of these drugs on isolated goat eye lenses was also evaluated. Permeation studies were conducted by putting 1 ml of formulation on the cornea fixed between the donor and receptor compartments of an all glass modified Franz diffusion cell and monitoring ciprofloxacin and diclofenac concentration in the receptor (containing normal saline or bicarbonate ringer solution under continuous stirring at 37±2°) spectrophotometrically at their respective absorption maxima, after 120 min. Paired isolated goat lenses (i.e. of same animal) were used to evaluate the effect of these drugs at selected concentrations against oxidative stress (1 mM hydrogen peroxide solution). After 24 h of incubation at 37°, the lens treated with test solution (hydrogen peroxide+drug in bicarbonate ringer solution) was estimated for soluble protein content and compared with control (only hydrogen peroxide). Among marketed eye drops of ciprofloxacin, Joxin (Jawa Pharmaceuticals) showed maximum in vitro transcorneal permeation (0.558%) while I-Gesic (Centaur Pharmaceuticals) showed maximum % in vitro permeation or in vitro ocular availability among diclofenac eye drops after 120 min of permeation. The soluble protein content estimation studies revealed that these drugs at selected concentrations (permeated after 120 min.) had no deleterious effect on eye lenses rather possessed protective effect, since all formulation showed more soluble protein content when compared with control.
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Affiliation(s)
- N Patidar
- Department of Pharmaceutics, B.R. Nahata College of Pharmacy, Mhow Neemuch Road, Mandsaur-458 001, India
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Abstract
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.
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Affiliation(s)
- Joseph Colin
- University Hospital Complex of Bordeaux, Peflegrin Hospital, Bordeaux, France.
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Donnenfeld ED, Holland EJ, Stewart RH, Gow JA, Grillone LR. Bromfenac ophthalmic solution 0.09% (Xibrom) for postoperative ocular pain and inflammation. Ophthalmology 2007; 114:1653-62. [PMID: 17445902 DOI: 10.1016/j.ophtha.2006.12.029] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2006] [Revised: 12/21/2006] [Accepted: 12/21/2006] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy and ocular safety of bromfenac ophthalmic solution 0.09% (Xibrom) for the treatment of postoperative inflammation and reduction of ocular pain in subjects who have undergone cataract extraction (CE). DESIGN Two phase III, multicenter, randomized, double-masked, parallel, placebo-controlled clinical trials were conducted under a common protocol. Data were pooled for analyses. PARTICIPANTS Five hundred twenty-seven subjects were sequentially assigned, according to a computer-generated randomization list (2:1), to bromfenac (n = 356) or a placebo (n = 171). INTERVENTION Subjects who underwent cataract surgery without prior antiinflammatory treatment with a postsurgical Summed Ocular Inflammation Score (SOIS) of > or =3 were treated with either bromfenac or the placebo, instilled twice daily for 14 days in the study eye, and observed for an additional 14 days for safety evaluation. MAIN OUTCOME MEASURE Cleared ocular inflammation with a SOIS of 0 (cells< or =5 and absence of flare after 14 days of treatment). Secondary outcomes included time to resolution of ocular inflammation, time to resolution of ocular pain, proportion of subjects with photophobia, and ocular adverse events. RESULTS Baseline characteristics were comparable between groups for age, gender, and race. The baseline mean SOIS was 3.7 in both groups. A greater proportion of bromfenac (64.0%) than placebo subjects (43.3%) achieved complete clearance of ocular inflammation at study day 15 (P<0.0001). The effect of bromfenac on clearance of ocular inflammation was as early as study day 3 after initiation of treatment, compared with the placebo (8.4% vs. 1.2%, P = 0.0012). The median time to resolution of ocular pain was 2 days (bromfenac) versus 5 days (placebo) (P<0.0001). Numbers of most ocular adverse events were lower for the bromfenac group than for the placebo group. Eye irritation was reported in a lower percentage of subjects for bromfenac (2.5%) versus placebo (4.7%), as were burning and stinging (1.4% vs. 2.5%), and photophobia (2.0% vs. 11.1%). CONCLUSIONS Bromfenac ophthalmic solution 0.09% effectively and rapidly cleared ocular inflammation and reduced ocular pain after CE. There were no serious ocular adverse events, and fewer adverse events were reported for the bromfenac group.
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Affiliation(s)
- Eric D Donnenfeld
- External Disease/Cornea Department, Manhattan Eye, Ear and Throat Hospital, New York, New York, USA.
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Lane SS, Modi SS, Lehmann RP, Holland EJ. Nepafenac ophthalmic suspension 0.1% for the prevention and treatment of ocular inflammation associated with cataract surgery. J Cataract Refract Surg 2007; 33:53-8. [PMID: 17189793 DOI: 10.1016/j.jcrs.2006.08.043] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2006] [Accepted: 08/21/2006] [Indexed: 11/21/2022]
Abstract
PURPOSE To determine whether nepafenac ophthalmic suspension 0.1% decreases the incidence and severity of inflammation and pain after cataract surgery with posterior chamber intraocular lens implantation. SETTING Twenty-one ophthalmology clinics in the United States. METHODS A randomized double-blind vehicle-controlled trial was conducted in which adult patients were randomly assigned to receive nepafenac 0.1% or vehicle beginning 1 day before surgery and continuing on the day of surgery (day 0) for 14 days. Patients were evaluated on days 1, 3, 7, and 14. The primary efficacy variable was the percentage of patients cured at day 14 (cure defined as aqueous cells score + aqueous flare score = 0). Other efficacy variables included percentage of patients who were pain free at all visits and aqueous cells, flare, and cells plus flare scores. RESULTS The mean age of the 476 patients (243 nepafenac, 233 vehicle) was 70 years (range 27 to 93 years). At day 14, 152 patients (62.6%) in the nepafenac group and 40 (17.2%) in the vehicle group were cured (P<.0001). A higher percentage of patients in the nepafenac group was pain free at all visits (P<.0001). Throughout the study, most nepafenac-treated patients were pain free (83.1% to 93.0%) compared with less than half the vehicle-treated patients (41.6% to 46.4%). The nepafenac group had lower mean aqueous cells, flare, and cells plus flare scores at all visits (P<.0001). No treatment-related ocular adverse events occurred in either group. CONCLUSION Nepafenac ophthalmic suspension 0.1% was safe and effective for preventing and treating ocular inflammation and pain associated with cataract surgery.
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Alvarez MT, Figueroa MS, Teus MA. Toxic keratolysis from combined use of nonsteroid anti-inflammatory drugs and topical steroids following vitreoretinal surgery. Eur J Ophthalmol 2006; 16:582-7. [PMID: 16952098 DOI: 10.1177/112067210601600413] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- M T Alvarez
- Departamento de Cirugia Vitreoretiniana, Vissum Madrid, Santa Hortensia 58, 28002 Madrid, Spain
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Waterbury LD, Flach AJ. Comparison of Ketorolac Tromethamine, Diclofenac Sodium, and Loteprednol Etabonate in an Animal Model of Ocular Inflammation. J Ocul Pharmacol Ther 2006; 22:155-9. [PMID: 16808675 DOI: 10.1089/jop.2006.22.155] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE The aim of this study was to compare the anti-inflammatory activities of ketorolac tromethamine 0.4% and 0.1%; diclofenac sodium 0.1%; and loteprednol etabonate 0.5% suspension in an animal model of ocular inflammation. METHODS An ocular inflammatory response was induced in New Zealand White rabbits by the intravenous (i.v.) administration of 10 microg/kg lipopolysaccharide (LPS). In study animals, 1 eye was treated topically with 50 microL of study medication (n = 8 animals per drug) and the other eye was treated topically with a 50-microL vehicle (buffered saline). In control animals (n = 8), both eyes were treated with vehicle. All animals were treated twice: 2 h and 1 h before LPS challenge. The breakdown of the blood-aqueous barrier in the anterior chamber was measured by fluorophotometry (FITC-dextran 30 mg/kg, i.v. given immediately after LPS challenge). Aqueous prostaglandin E(2) (PGE(2)) levels were measured using an enzyme-linked immunosorbent assay (ELISA) immunoassay. RESULTS Ketorolac 0.4% resulted in a nearly complete inhibition of endotoxin-induced increases in FITC-dextran and PGE(2) synthesis (P < 0.001 vs. vehicle). Diclofenac 0.1% had much less of an effect on these parameters (P < 0.01 vs. ketorolac 0.4%). Loteprednol 0.5% was no more effective than vehicle at inhibiting increases in FITC-dextran. CONCLUSIONS Ketorolac has greater anti-inflammatory effects than diclofenac and loteprednol.
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Schalnus R. Topical nonsteroidal anti-inflammatory therapy in ophthalmology. Ophthalmologica 2003; 217:89-98. [PMID: 12592044 DOI: 10.1159/000068563] [Citation(s) in RCA: 119] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2002] [Accepted: 11/01/2002] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Rainer Schalnus
- University Eye Hospital, Johann Wolfgang Goethe University, Frankfurt am Main, Germany.
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Hsu JKW, Johnston WT, Read RW, McDonnell PJ, Pangalinan R, Rao N, Smith RE. Histopathology of corneal melting associated with diclofenac use after refractive surgery. J Cataract Refract Surg 2003; 29:250-6. [PMID: 12648633 DOI: 10.1016/s0886-3350(02)01702-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE To describe the histopathology of the cornea in 3 cases of corneal melting associated with diclofenac therapy after refractive surgery procedures. SETTING Clinic and pathology laboratory. METHODS Three cases of corneal melting associated with diclofenac therapy (2 after laser in situ keratomileusis [LASIK] and 1 after mini-radial keratectomy enhancement of a LASIK undercorrection) were studied using patient and referring physician interviews, chart reviews, and histopathologic examination of the corneal tissue. RESULTS In all 3 cases, the flaps were dislocated and the stromal corneal bed was exposed. Diclofenac, generic or brand name, was used in all cases; in 1 case, both generic and brand name were used. Dosing and duration varied, but in all 3 cases diclofenac was used at least 4 times a day for at least 3 days after LASIK. Topical steroids were also prescribed, but 1 patient did not use them. Preoperative medical conditions were present in 2 cases. Histologic analysis showed evidence of an inflammatory response in advanced cases and keratolysis and lack of inflammatory cells in the flaps that were amputated early. CONCLUSIONS The use of generic or brand-name diclofenac with or without adjunctive topical steroids after LASIK can be associated with corneal melting when the LASIK flap is dislodged and the corneal stromal bed exposed. Caution is recommended with diclofenac use after LASIK in such cases.
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Abstract
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.
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Affiliation(s)
- Bruce I Gaynes
- Department of Ophthalmology, Rush University College of Medicine, Chicago, IL 60612, USA.
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Affiliation(s)
- Allan Joseph Flach
- Department of Ophthalmology, University of California, San Francisco, San Francisco, CA 94143, USA
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Tognetto D, Cecchini P, Sanguinetti G, Pedio M, Ravalico G. Comparative evaluation of corneal epithelial permeability after the use of diclofenac 0.1% and flurbiprofen 0.03% after phacoemulsification. J Cataract Refract Surg 2001; 27:1392-6. [PMID: 11566521 DOI: 10.1016/s0886-3350(01)00788-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE To assess the corneal epithelial function after prolonged topical administration of diclofenac 0.1% and flurbiprofen 0.03% single-dose eyedrops. SETTING University Eye Clinic of Trieste, Trieste, Italy. METHODS This randomized prospective study comprised 24 patients scheduled for phacoemulsification. The patients were randomly assigned to receive diclofenac or flurbiprofen eyedrops for 2 months after surgery. Corneal epithelial permeability was determined by fluorophotometry 7, 37, and 67 days after surgery. RESULTS An increase in corneal epithelial permeability was observed in the diclofenac group 37 and 67 days after surgery. No epithelial function alterations occurred in the flurbiprofen group. CONCLUSIONS Subclinical impairment of the epithelial function was observed during topical treatment with diclofenac 0.1% single-dose eyedrops after phacoemulsification. The mechanism responsible for this effect remains unknown.
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Affiliation(s)
- D Tognetto
- Eye Clinic, University of Trieste, Trieste, Italy.
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Congdon NG, Schein OD, von Kulajta P, Lubomski LH, Gilbert D, Katz J. Corneal complications associated with topical ophthalmic use of nonsteroidal antiinflammatory drugs. J Cataract Refract Surg 2001; 27:622-31. [PMID: 11311634 DOI: 10.1016/s0886-3350(01)00801-x] [Citation(s) in RCA: 97] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- N G Congdon
- The Wilmer Eye Institute, Dana Center for Preventive Ophthalmology, Baltimore, MD, USA
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Abstract
Cycloplegics, corticosteroids, and nonsteroidal anti-inflammatory drugs have been applied in the treatment of postoperative inflammation following cataract extraction. Of these, topical preparations of nonsteroidal anti-inflammatory drugs, such as ketorolac tromethamine 0.5% and diclofenac sodium 0.1%, offer comparable efficacy to corticosteroids in the reduction of postoperative inflammation, and offer lower risks of adverse events in most patients. Comparative studies of these drugs from the past 5 years are highlighted.
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Affiliation(s)
- J N Simone
- Heart of America Eye Care, PA, Merriam, Kansas, USA.
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Abstract
Postoperative ocular inflammation following cataract surgery is related to the risk of complications like corneal edema, intraocular pressure spikes, cystoid macular edema, and posterior capsule opacification. The degree of postoperative inflammation following cataract surgery is linked to several surgery-dependent factors such as surgical technique, intraocular lens type, and also patient-dependent factors such as history of inflammatory disease and degree of iris pigmentation. During the past decade, major advances have occurred in cataract surgery techniques, equipment, and pharmacologic strategies that decrease the degree of postoperative inflammation following cataract surgery and reduce patients' risk for inflammation-related complications. This article reviews the most recent literature regarding the control of cataract surgery-induced intra-ocular inflammation.
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Affiliation(s)
- S M El-Harazi
- Department of Ophthalmology and Visual Science, The University of Texas Health Science Center, Houston, Texas, USA.
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Masket S. Truth and consequences. Ophthalmology 2001; 108:1-4. [PMID: 11228628 DOI: 10.1016/s0161-6420(00)00523-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Flach A. Letters to the Editor. Ophthalmology 2001. [DOI: 10.1016/s0161-6420(00)00522-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Bridge HS, Montgomery CJ, Kennedy RA, Merrick PM. Analgesic efficacy of ketorolac 0.5% ophthalmic solution (Accular) in paediatric strabismus surgery. Paediatr Anaesth 2000; 10:521-6. [PMID: 11012956 DOI: 10.1046/j.1460-9592.2000.00534.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This prospective double-blind study was designed to assess the analgesic efficacy of ketorolac 0.5% ophthalmic solution compared with placebo in 30 healthy children undergoing extraocular muscle recession for correction of strabismus. After paracetamol 20 mg.kg-1 preoperatively, a standard anaesthetic was given. There were no significant differences in Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and faces pain scale (FPS) scores, requirement for supplementary analgesia or in postoperative vomiting between the two groups over the following 24 h. This study did not demonstrate improved postoperative analgesia when topical ketorolac eye drops were given in addition to paracetamol. This observed lack of efficacy may reflect difficulties in the use of CHEOPS and FPS in this age group with this pain model.
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Affiliation(s)
- H S Bridge
- Department of Anaesthesia and Ophthamology, British Columbia's Children's Hospital and University of British Columbia, Vancouver, Canada
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Snyder RW, Siekert RW, Schwiegerling J, Donnenfeld E, Thompson P. Acular as a single agent for use as an antimiotic and anti-inflammatory in cataract surgery. J Cataract Refract Surg 2000; 26:1225-7. [PMID: 11008052 DOI: 10.1016/s0886-3350(00)00439-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To assess the safety and effectiveness of ketorolac tromethamine 0. 5% (Acular) as a cost-efficient single agent to prevent intraoperative miosis and postoperative inflammation in cataract surgery. METHODS Both eyes of 26 patients were randomized to receive Acular preoperatively and postoperatively or flurbiprofen sodium (Ocufen) preoperatively and prednisolone acetate 1% (Pred Forte) postoperatively. Time scheduled between procedures was from 2 weeks to 1 month. Pupil dilation was measured preoperatively, intraoperatively, and at the end of surgery. Cell and flare were measured 1 day, 1 week, and 1 month postoperatively. RESULTS A comparison of the Acular and the Ocufen/Pred Forte groups (n=22) showed no statistically significant differences in dilation (preoperative versus postpostoperative) or cell and flare postoperatively. CONCLUSIONS Using Acular as a single agent was as effective as the combination of preoperative Ocufen and postoperative Pred Forte in preventing intraoperative miosis and postoperative inflammation in cataract surgery. The use of Acular as a single agent could save the expense of using separate anti-inflammatory and antimiotic preparations preoperatively and postoperatively, enhancing convenience for the surgeon and surgical facility.
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Affiliation(s)
- R W Snyder
- Department of Ophthalmology, The University of Arizona Health Science Center, Tucson, Arizona, USA
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Schauersberger J, Kruger A, Müllner-Eidenböck A, Petternel V, Abela C, Svolba G, Amon M. Long-term disorders of the blood-aqueous barrier after small-incision cataract surgery. Eye (Lond) 2000; 14 ( Pt 1):61-3. [PMID: 10755102 DOI: 10.1038/eye.2000.13] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To determine the long-term function of the blood-aqueous barrier after small-incision cataract surgery with implantation of a foldable intraocular lens. METHODS The blood-aqueous barrier function in 74 eyes of 62 patients who underwent cataract surgery was examined using a laser flare-cell meter. The measurements were performed pre-operatively and post-operatively between 12 and 35 months after surgery. For statistical analysis a linear regression was used. The study was designed as a single cohort study, with comparison of pre- and post-operative values. RESULTS Highly statistically significant differences (p < 0.0001) were found between pre-operative flare values and those measured at the final visit. The linear regression model showed significantly higher flare values post-operatively compared with those measured pre-operatively. Other variables such as incision technique, sex, operation time, phaco time and systemic disease had no influence on this outcome. CONCLUSION The results suggest that there is persistent blood-aqueous barrier dysregulation even several years after cataract surgery.
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Affiliation(s)
- J Schauersberger
- Department of Ophthalmology, University Hospital of Vienna, Austria.
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Abstract
The current state of cataract surgery for the millennium may be stated as "minimally invasive techniques." This review presents recent articles on the perioperative use of antibiotics (primarily fluoroquinolones), nonsteroidal antiinflammatory drugs (Voltaren and ketorolac), and new corticosteroids (rimexolone and loteprednol etabonate). Preoperative topical application of ofloxacin or ciprofloxacin results in a satisfactory minimal inhibitory concentration for most pathogens. However, one cannot determine the actual effect of intraoperative antibiotics on acute postoperative endophthalmitis, because of its low overall incidence. Nonsteroidal antiinflammatory drugs, especially Voltaren, may offer equivalent antiinflammatory efficacy (for both postoperative inflammation and cystoid macular edema) without the typically corticosteroid-associated adverse events. Rimexolone and loteprednol etabonate, two new corticosteroids, may offer good antiinflammatory efficacy with greatly reduced risk for elevation of intraocular pressure.
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Affiliation(s)
- S Rowen
- Mercy Medical Center, Baltimore, MD 21202, USA
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