Efficacy of diclofenac eyedrops in preventing postoperative inflammation and long-term cystoid macular edema. Italian Diclofenac Study Group

Comparison of the efficacy and safety of non-steroidal anti-inflammatory drugs and corticosteroid drugs for prevention of cystoid macular edema after cataract surgery

INTRODUCTION

To compare the efficacy and safety of non-steroidal anti-inflammatory drugs (NSAID), corticosteroid (CS), and a combination of both drugs to prevent cystoid macular edema (CME) after cataract surgery.

METHODS

We searched Pubmed, Cochrane Library, and Embase electronic databases to assess the relevant randomized controlled trials (RCTs) up to 28 April 2021. Network meta-analysis was registered on PROSPERO (CRD42020182520).

RESULTS

Twenty-four RCTs were included in this review. The NSAID and combination of both drugs were significantly reduced the risk of developing CME than CS alone in non-diabetics and mix populations. In the ranking profiles, the combination therapy showed a significant advantage over the single drugs and was less likely to develop CME. Diclofenac was the most likely to reduce the odds of developing CME compared with bromfenac and nepafenac. Dexamethasone was the most likely to reduce the odds of developing CME compared with betamethasone and fluorometholone.

CONCLUSION

NSAID combination with CS has significantly reduced the risk of developing CME postoperatively than the single drug. Diclofenac was superior to bromfenac and nepafenac in preventing CME. Dexamethasone was superior to betamethasone and fluorometholone in preventing CME.

Non-steroidal anti-inflammatory agents for treating cystoid macular edema following cataract surgery

BACKGROUND

Cataract surgery is the most common ambulatory incisional surgery performed in the USA. Cystoid macular edema (CME), the accumulation of fluid in the central retina due to leakage from dilated capillaries, is the most common cause of vision impairment following cataract surgery. Acute CME, defined as CME of less than four months' duration, often resolves spontaneously. CME that persists for four months or longer is termed chronic CME. Non-steroidal anti-inflammatory drugs (NSAIDs) have been used to treat CME. This update adds new evidence and analyses to the previously published review.

OBJECTIVES

To examine the effectiveness of NSAIDs in the treatment of CME following cataract surgery.

SEARCH METHODS

We searched the CENTRAL (2022, Issue 3); Ovid MEDLINE; Embase; PubMed; LILACS; mRCT (discontinued in 2014, last searched August 2011), ClinicalTrials.gov, and WHO ICTRP databases. We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 20 March 2022.   SELECTION CRITERIA: We included randomized controlled trials evaluating the effects of NSAIDs for CME following cataract surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all titles and abstracts, reviewed full-text publications against eligibility criteria, independently extracted data from newly included trials and assessed risk of bias for each included trial. We contacted trial authors for clarification or to request missing information. We provided a narrative synthesis of all included trials and their results. For continuous and dichotomous outcomes, we separately performed pooled analysis and reported mean difference (MD) and risk ratio (RR) as well as the associated 95% confidence interval (CI) whenever feasible. Two review authors independently graded the overall certainty of the evidence for each outcome using the GRADE approach.

MAIN RESULTS

We included nine trials with a total of 390 participants (393 eyes). Study participants' mean age was 72.2 years (interquartile range [IQR] 68.8 to 73.6) and 72% were women (IQR 69% to 74%). Three trials included participants with acute CME, and four included participants with chronic CME; the remaining two trials enrolled both participants with acute and chronic CME or participants with unknown CME duration. We assessed trials as having unclear (33%) or high risk of bias (67%). Visual improvement of two or more lines at the end of treatment  Data from one trial in participants with acute CME show no treatment effect of topical ketorolac compared to placebo (RR 2.00, 95% CI 0.46 to 8.76; 22 participants). Data from a three-arm trial in participants with acute CME demonstrate that, when compared with topical prednisolone, topical ketorolac (RR 1.33, 95% CI 0.58 to 3.07; 17 participants) or topical ketorolac and prednisolone combination therapy (RR 1.78, 95% CI 0.86 to 3.69; 17 participants) may have little or no effect on visual improvement. Results of subgroup analysis from two studies in participants with chronic CME suggest that, after treatment for 90 days or longer, NSAIDs may increase participants' likelihood of visual improvement by 1.87 fold (RR 2.87, 95% CI 1.58 to 5.22; I2 = 33%; 2 trials, 121 participants) relative to placebo. However, there was no evidence of treatment effects in the subgroup with two months of treatment or less (RR 0.72, 95% CI 0.30 to 1.73; P = 0.19, I2 = 41%; 2 trials, 34 participants). Overall, this evidence is very low certainty.  A single-study estimate in patients with mixed CME indicates that topical diclofenac may increase the likelihood of visual improvement by 40% when compared to topical ketorolac (RR 1.40, 95% CI 1.02 to 1.94; 68 participants). However, the same trial reported no difference between the groups in mean final visual acuity in Snellen lines (MD 0.40, 95% CI -0.93 to 1.73). A three-arm trial in patients with mixed CME reporting visual changes in ETDRS letters in comparisons between ketorolac and diclofenac (34 participants) or bromfenac (34 participants) suggests no evidence of effects. Overall, NSAIDs may slightly improve visual acuity in participants with mixed CME but the evidence is very uncertain. Persistence of improvement of vision one month after discontinuation of treatment One trial of participants with chronic CME tested oral indomethacin (RR 0.40, 95% CI 0.10 to 1.60; 20 participants) and the other compared topical ketorolac to placebo (RR 4.00, 95% CI 0.51 to 31.1; 26 participants). While there is no evidence of treatment effects, evidence suggests substantial between-group heterogeneity (P = 0.07, I2 = 69.9%; very low-certainty evidence). None of the trials in patients with acute or mixed CME reported this outcome. Proportion of participants with improvement in leakage on fundus fluorescein angiography One three-arm trial in participants with acute CME shows that, when compared with topical prednisolone, there is no treatment benefit of topical ketorolac (RR 1.11, 95% CI 0.45 to 2.75; 17 participants) or topical ketorolac and topical prednisolone combination therapy (RR 1.56, 95% CI 0.72 to 3.38; 17 participants). This evidence is very low certainty. The combined estimate from two trials in participants with chronic CME indicates NSAIDs have little to no effect over placebo on improving leakage (RR 1.93, 95% CI 0.62 to 6.02; 40 participants; very low-certainty evidence). Neither of the trials in patients with mixed CME reported this outcome. Proportion of participants with improved contrast sensitivity Very low-certainty evidence from one trial in participants with acute CME shows no treatment benefit of ketorolac (RR 1.11, 95% CI 0.45 to 2.75; 17 participants) or ketorolac and prednisolone combination therapy (RR 1.78, 95% CI 0.86 to 3.69; 17 participants) compared with topical prednisolone. None of the trials in patients with chronic or mixed CME reported this outcome. Proportion of participants with improved central macular thickness on optical coherence tomography; measures of quality of life No included trial reported these outcomes. Adverse effects Most trials observed no differences in ocular adverse events, such as corneal toxicity or elevated intraocular pressure, between comparison groups.

AUTHORS' CONCLUSIONS

Evidence on effects of NSAIDs in patients with CME is very uncertain and further investigation is warranted. Our findings are limited by small sample sizes, and heterogeneity in interventions, assessments, and reporting of clinically important outcomes.

Topical Anti-Inflammatory Agents for Non-Infectious Uveitis: Current Treatment and Perspectives

Non-infectious uveitis represents a heterogenous group of immune-mediated ocular diseases, which can be associated with underlying systemic disease. While the initial choice of treatment of non-infectious uveitis depends on a number of factors such as anatomical location and degree of inflammation, topical therapies often remain the initial choice of non-invasive therapy. In this narrative review, we aim to describe the literature on non-infectious uveitis, with specific focus on the current perspective on topical anti-inflammatory therapy.

Measuring Anterior Chamber Inflammation After Cataract Surgery: A Review of the Literature Focusing on the Correlation with Cystoid Macular Edema

Cystoid macular edema (CME) is an infrequent, though potentially visually impairing, complication after uneventful cataract surgery. Rupture of the blood-aqueous barrier, with leakage of serum proteins into the aqueous humour, is the main pathogenic factor. However, only a few studies investigated the potential correlation between anterior chamber (AC) inflammation and the risk of cystoid macular changes occurring after surgery. This review aims to identify evidence of a correlation between AC inflammation and the risk of pseudophakic CME. One hundred eighty-seven prospective trials investigating AC inflammation after uncomplicated cataract surgery were identified. Methods of analysis of AC inflammation and the frequency of macular changes were recorded. In the majority (51%) of the studies, inflammation was assessed by clinical grading, followed by laser flare and cell photometry (LFCP) (42%) and aqueous humour sample (4%). Few studies (4%) adopted a combined LFCP and aqueous sample or clinical grading analysis. Sixteen (9%) studies investigated AC inflammation and macular changes by OCT (7%) or fluorescein angiography (2%). Correlation between the amount of postoperative AC inflammation and frequency of CME was documented in 7 studies, not confirmed in 2 studies, and not examined in the other 7. LFCP, more than the other methods of analysis, correlated with the frequency of CME postoperatively. Investigation of the relationship between AC inflammation and the risk of CME changes requires the adoption of quantitative methods of analysis of the inflammatory response after surgery. For this purpose, due to the low level of inflammation in the AC after uncomplicated cataract surgery, LFCP, more than subjective clinical grading, seems a more sensitive and reproducible method of measurement. Inflammation assessment after cataract surgery has a potential role in predicting the risk of CME development and may help to titrate the duration and intensity of treatment in relation to the surgical inflammatory response.

Comparison of the Efficacy and Safety of two Formulations of Diclofenac Sodium 0.1 % Eyedrops in Controlling Postoperative Inflammation after Cataract Surgery

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.

Prophylactic non-steroidal anti-inflammatory drugs for the prevention of macular oedema after cataract surgery

BACKGROUND

Macular oedema (MO) is the accumulation of extracellular fluid in the central retina (the macula). It may occur after cataract surgery and may give rise to poor visual outcome, with reduced visual acuity and distortion of the central vision. MO is often self-limiting with spontaneous resolution, but a small proportion of people with chronic persistent MO may be difficult to treat. Chronic oedema may lead to the formation of cystic spaces in the retina termed 'cystoid macular oedema' (CMO). Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used in cataract surgery and may reduce the chances of developing MO.

OBJECTIVES

The aim of this review is to answer the question: is there evidence to support the prophylactic use of topical NSAIDs either in addition to, or instead of, topical steroids postoperatively to reduce the incidence of macular oedema (MO) and associated visual morbidity.

SEARCH METHODS

We searched a number of electronic databases including CENTRAL, MEDLINE and Embase. Date last searched 2 September 2016.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in which adult participants had undergone surgery for age-related cataract. We included participants irrespective of their baseline risk of MO, in particular we included people with diabetes and uveitis. We included trials of preoperative and/or postoperative topical NSAIDs in conjunction with postoperative topical steroids. The comparator was postoperative topical steroids alone. A secondary comparison was preoperative and/or postoperative topical NSAIDs alone versus postoperative topical steroids alone.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, assessed risk of bias and extracted data using standard methods expected by Cochrane. We pooled data using a random-effects model. We graded the certainty of the evidence using GRADE and considered the following: risk of bias of included studies, precision of the effect estimate, consistency of effects between studies, directness of the outcome measure and publication bias.

MAIN RESULTS

We identified 34 studies that were conducted in the Americas, Europe, the Eastern Mediterranean region and South-East Asia. Over 5000 people were randomised in these trials. The majority of studies enrolled one eye per participant; a small subset (4 trials) enrolled a proportion of people with bilateral surgery. Twenty-eight studies compared NSAIDs plus steroids with steroids alone. Six studies compared NSAIDs with steroids. A variety of NSAIDs were used, including ketorolac, diclofenac, nepafenac, indomethacin, bromfenac, flurbiprofen and pranopfen. Follow-up ranged from one to 12 months. In general, the studies were poorly reported. We did not judge any of the studies at low risk of bias in all domains. Six studies were funded by industry, seven studies were funded from non-industry sources, and the rest of the studies did not report the source of funding.There was low-certainty evidence that people receiving topical NSAIDs in combination with steroids may have a lower risk of poor vision due to MO at three months after cataract surgery compared with people receiving steroids alone (risk ratio (RR) 0.41, 95% confidence interval (CI) 0.23 to 0.76; eyes = 1360; studies = 5; I2 = 5%). We judged this to be low-certainty evidence because of risk of bias in the included studies and indirectness, as the extent of visual loss was not always clear. Only one study reported poor vision due to MO at 12 months and we judged this to be very low-certainty evidence as there were only two events. Quality of life was only reported in one of the 34 studies comparing NSAIDs plus steroids versus steroids alone, and it was not fully reported, other than to comment on lack of differences between groups. There was evidence of a reduced risk of MO with NSAIDs at three months after surgery, but we judged this to be low-certainty due to risk of bias and publication bias (RR 0.40, 95% CI 0.32 to 0.49; eyes = 3638; studies = 21). There was inconsistent evidence on central retinal thickness at three months (I2 = 87%). Results ranged from -30.9 µm in favour of NSAIDs plus steroids to 7.44 µm in favour of steroids alone. Similarly, data on best corrected visual acuity (BCVA) were inconsistent, but nine out of 10 trials reporting this outcome found between-group differences in visual acuity of less than 0.1 logMAR.None of the six studies comparing NSAIDs alone with steroids reported on poor vision due to MO at three or 12 months. There was low-certainty evidence that central retinal thickness was lower in the NSAIDs group at three months (mean difference (MD) -22.64 µm, 95% CI -38.86 to -6.43; eyes = 121; studies = 2). Five studies reported on MO and showed a reduced risk with NSAIDs, but we judged this evidence to be of low-certainty (RR 0.27, 95% CI 0.18 to 0.41; eyes = 520). Three studies reported BCVA at three months and the results of these trials were inconsistent, but all three studies found differences of less than 0.1 logMAR between groups.We did not note any major adverse events - the main consistent observation was burning or stinging sensation with the use of NSAIDs.

AUTHORS' CONCLUSIONS

Using topical NSAIDs may reduce the risk of developing macular oedema after cataract surgery, although it is possible that current estimates as to the size of this reduction are exaggerated. It is unclear the extent to which this reduction has an impact on the visual function and quality of life of patients. There is little evidence to suggest any important effect on vision after surgery. The value of adding topical NSAIDs to steroids, or using them as an alternative to topical steroids, with a view to reducing the risk of poor visual outcome after cataract surgery is therefore uncertain. Future trials should address the remaining clinical uncertainty of whether prophylactic topical NSAIDs are of benefit, particularly with respect to longer-term follow-up (at least to 12 months), and should be large enough to detect reduction in the risk of the outcome of most interest to patients, which is chronic macular oedema leading to visual loss.

Topical Nonsteroidal Anti-inflammatory Drugs and Cataract Surgery: A Report by the American Academy of Ophthalmology

OBJECTIVE

To review the available evidence on the effectiveness of prophylactic topical nonsteroidal anti-inflammatory drugs (NSAIDs) in preventing vision loss resulting from cystoid macular edema (CME) after cataract surgery.

METHODS

Literature searches of the PubMed and the Cochrane Library databases were last conducted on January 21, 2015, with no date restrictions. The searches retrieved 149 unique citations. The first author reviewed the abstracts of these articles and selected 27 articles of possible clinical relevance for full-text review. Of these 27 articles, 12 were deemed relevant to analyze in full. Two additional articles were identified from the reference list of the selected articles, and another article was identified from a national meeting. The panel methodologist assigned ratings of level of evidence to each of the selected citations.

RESULTS

Nonsteroidal anti-inflammatory drug therapy was effective in reducing CME detected by angiography or optical coherence tomography (OCT) and may increase the speed of visual recovery after surgery when compared directly with placebo or topical corticosteroid formulations with limited intraocular penetration. However, the use of NSAIDs did not alter long-term (≥3 months) visual outcomes. Furthermore, there was no evidence that the benefits observed with NSAID therapy could not be obtained similarly with equivalent dosing of a corticosteroid. The reported impression that there is a pharmacologic drug synergy from the use of both an NSAID and a corticosteroid is not supported by the literature. There is no uniform method of reporting CME in the literature, which prevents accurate assessment of its incidence and response to anti-inflammatory therapies.

CONCLUSIONS

Cystoid macular edema after cataract surgery has a tendency to resolve spontaneously. There is a lack of level I evidence that supports the long-term benefit of NSAID therapy to prevent vision loss from CME at 3 months or more after cataract surgery. Although dosing of NSAIDs before surgery may hasten the speed of visual recovery in the first several weeks after cataract surgery, there is no evidence that this practice affects long-term visual outcomes. Standardized reporting of CME based on OCT may allow for more uniform quantitation of its incidence and more reliable assessment of treatment outcomes.

Topical nonsteroidal anti-inflammatory drugs for macular edema

Nonsteroidal anti-inflammatory drugs (NSAIDs) are nowadays widely used in ophthalmology to reduce eye inflammation, pain, and cystoid macular edema associated with cataract surgery. Recently, new topical NSAIDs have been approved for topical ophthalmic use, allowing for greater drug penetration into the vitreous. Hence, new therapeutic effects can be achieved, such as reduction of exudation secondary to age-related macular degeneration or diabetic maculopathy. We provide an updated review on the clinical use of NSAIDs for retinal diseases, with a focus on the potential future applications.

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

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

Non-steroidal anti-inflammatory agents for treating cystoid macular oedema following cataract surgery

BACKGROUND

Cystoid macular oedema (CMO) is the accumulation of fluid in the central retina (the macula) due to leakage from dilated capillaries. It is the most common cause of poor visual outcome following cataract surgery. The exact cause is unclear. Acute CMO, defined as oedema of less than four months duration, often resolve spontaneously. CMO that persists for four months or more is termed chronic CMO. Different types of non-steroidal anti-inflammatory agents (NSAIDs) are used in the treatment of CMO which may be delivered topically or systemically.

OBJECTIVES

To examine the effectiveness of NSAIDs in the treatment of CMO following cataract surgery.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2011, Issue 7), MEDLINE (January 1950 to August 2011), EMBASE (January 1980 to August 2011), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to August 2011), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com) (August 2011) and ClinicalTrials.gov (www.clinicaltrials.gov) (August 2011). We searched the reference lists of identified trials. We searched conference abstracts (sessions related to cataract) in The Association for Research in Vision and Ophthalmology (ARVO) 1975 to 2011. We contacted experts in the field and NSAIDs manufacturers for details on published and unpublished trials.There were no language or date restrictions in the search for trials. The electronic databases were last searched on 5 August 2011.

SELECTION CRITERIA

We included randomised controlled trials evaluating the effects of NSAIDs in the treatment of CMO following cataract surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data. Since considerable heterogeneity was observed between studies we did not conduct meta-analyses.

MAIN RESULTS

Seven trials involving a total of 266 participants were included. Four trials studied the effects of NSAIDs in chronic CMO while the other three examined the effect of NSAIDs in acute CMO. Of the studies examining chronic CMO, one study enrolled 120 participants, but the remainder had 34 or fewer participants. Four different NSAIDs were used and administered in different ways. Indomethacin was used orally and was found to be ineffective for chronic CMO in one trial. Topical fenoprofen appeared effective but not statistically significantly so for chronic CMO in another small trial. Treatment with topical 0.5% ketorolac for chronic CMO was found to be effective in two trials. Three trials examined the effect of topical NSAIDs on acute CMO. The comparisons among these studies were of an NSAID to placebo, prednisolone or another NSAID. The study design differed between the studies in other important aspects thus they could not be combined in a meta-analysis.

AUTHORS' CONCLUSIONS

This review found two trials which showed that topical NSAID (0.5% ketorolac tromethamine ophthalmic solution) has a positive effect on chronic CMO and two trials which revealed no significant difference between comparative groups. As such, the effects of NSAIDs in acute and chronic CMO remain unclear and needs further investigation.

Intravitreal injection of commercially available ketorolac tromethamine in eyes with diabetic macular edema refractory to laser photocoagulation

PURPOSE

To evaluate the short-term effect of a single intravitreal injection of commercially available ketorolac tromethamine (KT) in eyes with diabetic macular edema refractory to laser photocoagulation.

METHODS

Prospective interventional case series. Twenty five patients with diabetic macular edema refractory to laser photocoagulation received a single intravitreal injection of commercially available KT (Toradol®), in a dose of 3000 µg. Examination included assessment of ETDRS-best corrected visual acuity (BCVA), measurement of intraocular pressure and high resolution imaging by optical coherence tomography, preoperatively and 7, 15, and 30 days postoperatively.

RESULTS

In the follow up visits at 7, 15 and 30 days, BCVA had improved five or more letters in 20% (95% confidence interval, 7.7-38.9%), 16% (95% confidence interval, 5.3-34.2%) and 28% (95% confidence interval, 13.2-47.7%) respectively. An improvement in macular thickness was also observed, although it has not been statistically significant.

CONCLUSION

This pilot study showed that a single intravitreal injection of 3000 µg of commercial KT led to a short-term improvement of visual acuity in approximately 30% of eyes with diabetic macular edema refractory to laser photocoagulation.

Penetration of topically applied diclofenac and ketorolac into the aqueous humour and subretinal fluid: randomized clinical trial

OBJECTIVE

To determine the level of intraocular penetration of diclofenac sodium and ketorolac tromethamine into the aqueous humour and subretinal fluid.

DESIGN

Prospective randomized clinical trial.

PARTICIPANTS

Twenty eyes scheduled for retinal detachment surgery and 17 eyes scheduled for cataract surgery.

METHODS

Patients with retinal detachment were randomly assigned to receive either topical ketorolac (n = 11) or topical diclofenac (n = 9). Subretinal fluid samples were collected 30-60 minutes after the administration of the last dose. In addition, 17 patients with cataract were randomly assigned to receive topical ketorolac (n = 9) or topical diclofenac (n = 8). The aqueous humour samples were collected 30 minutes after the administration of the last dose. Drug concentrations were determined by high-performance liquid chromatography fluorescence.

RESULTS

The mean diclofenac concentration in the subretinal fluid was 42.31 (SD 24.89) ng/µL. Ketorolac was undetectable in the subretinal fluid in all patients who received it because ketorolac tromethamine levels were under the limit of detection. In the aqueous humour, mean diclofenac concentration was 4.98 (SD 4.56) ng/µL, and mean ketorolac concentration was 20.17 (SD 12.21) ng/µL. Topical administration of diclofenac sodium yielded 8.4 times greater drug concentration in the subretinal fluid than in the aqueous humour. Aqueous humour concentrations of ketorolac were higher than those of diclofenac (p = 0.019).

CONCLUSIONS

The concentration in the subretinal fluid of topically applied diclofenac was higher than that of ketorolac; and topical ketorolac penetrated into the aqueous humour better than diclofenac did. This suggests that diclofenac can be used more effectively in events related to posterior segment and ketorolac in anterior segment events.

Nonsteroidal anti-inflammatory drugs in ophthalmology

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

Intraocular lens as a drug delivery system for dexamethasone

PURPOSE

To evaluate the effect of an intraocular lens (IOL) coated with dexamethasone on postoperative inflammation after cataract surgery.

METHODS

Clear lens extraction was performed bilaterally in eight 8-week-old rabbits. An uncoated silicone IOL (CeeOn; AMO, Santa Ana, CA, USA) was implanted in one randomly selected eye. In the other eye, the same silicone IOL model was implanted but was coated with dexamethasone. Aqueous humour was obtained preoperatively and on days 1, 3, 7, 14 and 28 postoperatively. Three inflammatory parameters were measured and compared between the eyes: prostaglandin E2 (PGE2), white blood cell (WBC) count and protein content. The animals were killed on day 28 postoperatively.

RESULTS

PGE2 levels measured on days 1, 3 and 7 were significantly lower in eyes with a coated IOL compared to eyes with an uncoated IOL (p < 0.01). The WBC count was significantly lower in eyes with a coated IOL on days 1 (p < 0.01) and 3 (p < 0.05). There was significantly less protein in eyes with a coated IOL on days 1 and 3 (p < 0.01).

CONCLUSION

Coating a silicone IOL with dexamethasone significantly reduced postoperative inflammation after clear lens extraction in rabbits.

Treatment of cystoid macular edema with the new-generation NSAID nepafenac 0.1%

Purpose:

To describe the use of nepafenac 0.1% for cystoid macular edema (CME).

Methods:

This was a multicenter retrospective review of 22 CME cases (20 patients) treated with nepafenac 0.1% (six with concomitant prednisolone acetate 1%) from December 2005 to April 2008: three acute pseudophakic CME cases, 13 chronic/recalcitrant pseudophakic CME cases, and six cases of uveitic CME. Pre- and post-treatment retinal thickness and visual acuity were reported.

Results:

Following treatment for six weeks to six months, six eyes with uveitic CME showed a mean retinal thickness improvement of 227 ± 168.1 μm; mean best-corrected visual acuity (BCVA) improvement was 0.36 ± 0.20 logMAR. All three cases of acute pseudophakic CME improved after four to 10 weeks of nepafenac, with a mean improvement in retinal thickness of 134 ± 111.0 μm. BCVA improved in two patients (0.16 and 0.22 logMAR) but not in the third due to underlying retinal pigment epithelium changes. Thirteen eyes with chronic/recalcitrant pseudophakic CME demonstrated a mean improvement in retinal thickness of 178 ± 128.7 μm after nepafenac and mean BCVA improvement of 0.33 ± 0.19 logMAR.

Conclusion:

The positive outcomes of these 22 eyes strongly suggest that nepafenac 0.1% is a promising drug for the treatment of CME. Additional study under randomized controlled conditions is warranted.

Effect of bromfenac ophthalmic solution on ocular inflammation following cataract surgery

PURPOSE

This study compared the post-cataract surgery anti-inflammatory effects of topical treatment with 0.1% bromfenac, 0.1% betamethasone or both on postoperative anterior chamber inflammation and corneal swelling.

METHODS

Seventy-two patients with no eye disease other than cataract were enrolled in a prospective, randomized study to undergo phacoemulsification combined with intraocular lens implantation. After cataract surgery, patients were randomized to treatment with bromfenac, betamethasone or both agents. Twenty-five eyes were assigned to bromfenac, 23 to betamethasone and 24 to the combined treatment group. Inflammatory reactions in the anterior chamber were measured with laser flare photometry preoperatively and at 1 and 3 days, 1 and 2 weeks, and 1 and 2 months postoperatively. Intraocular pressure (IOP) and corneal thickness were measured at the same time-points. Best corrected visual acuity (BCVA) was measured preoperatively and at 2 days, 1 and 2 weeks, and 1 and 2 months postoperatively. Specular microscope endothelial photography of the central region of the cornea was performed preoperatively and at 3 months after surgery.

RESULTS

There were no significant differences among the bromfenac, betamethasone and combined treatment groups in BCVA, IOP, aqueous flare or corneal thickness. Cystoid macular oedema was present in one eye treated with betamethasone.

CONCLUSIONS

There were no significant differences in anti-inflammatory effects among the three treatments. These findings suggest that bromfenac is as effective as betamethasone in minimizing inflammatory reactions after cataract surgery.

Postoperative finding in the intraoperative floppy-iris syndrome

We describe a postoperative finding discovered before surgery in the second eye of a patient who had intraoperative floppy-iris syndrome (IFIS). Recognizing the risk for IFIS is important to anticipate and manage the syndrome and ensure successful cataract surgery. Obtaining the right information about the past and present intake of alpha-blockers is mandatory.

Incidence of visually significant pseudophakic macular edema after uneventful phacoemulsification in patients treated with nepafenac

PURPOSE

To compare the incidence of visually significant pseudophakic macular edema after uneventful phacoemulsification in patients treated postoperatively with topical prednisolone and those treated with topical prednisolone and nepafenac 0.1% suspension (Nevanac).

SETTING

Edward S. Harkness Eye Institute of Columbia University, New York, New York, USA.

METHODS

This retrospective chart review was of consecutive patients who had phacoemulsification at a single institute and were given topical prednisolone alone or topical prednisolone and nepafenac to prevent cystoid macular edema. Data collection included preexisting ocular and systemic diseases, concurrent use of ocular and systemic medications, surgical technique, intraoperative and postoperative complications, follow-up visual and ocular assessments, and postoperative optical coherence tomography (OCT) assessment for macular edema.

RESULTS

Postoperatively, 240 patients were treated with prednisolone and 210 patients, with prednisolone-nepafenac. Preoperatively, the 2 groups were demographically and clinically comparable in sex distribution (P = .8400), history of diabetes (P = .7267), hypertension or cardiac disease (P = .8690), and concurrent use of oral nonsteroidal anti-inflammatory drugs (P = .7303). Iris manipulation was done in 16 patients in the prednisolone-alone group and 10 patients in the prednisolone-nepafenac group (P = .3876). Capsule staining was done in 5 patients and 4 patients, respectively. All patients were followed for at least 1 month postoperatively. Visually significant pseudophakic macular edema was documented by OCT in 5 patients treated with prednisolone alone and in no patients treated with prednisolone and nepafenac (P = .0354). No significant intraoperative or postoperative complications were reported.

CONCLUSION

Patients treated with topical prednisolone alone had a significantly higher incidence of visually significant pseudophakic macular edema after uneventful cataract surgery than those treated with topical prednisolone and nepafenac.

Diclofenac prevents an early event of macular thickening after cataract surgery in patients with diabetes

PURPOSE

This study compares the effect of topical diclofenac with that of betamethasone against postoperative cystoid macular edema (CME) following cataract surgery in patients with non- and mild nonproliferative diabetic retinopathy.

METHODS

Forty-six (46) consecutive patients with mild nonproliferative- or nondiabetic retinopathy who had bilateral and symmetrical cataracts underwent uncomplicated cataract surgery in both eyes (92 eyes in total). Postoperatively, topical diclofenac was applied 4 times daily for 1 eye, and topical betamethasone 4 times daily for the other eye in each patient. Best corrected logMAR visual acuity (BCVA), averaged foveal thickness (FT) as measured by optical coherence tomography (OCT), and intraocular pressure (IOP) were monitored preoperatively, and also postoperatively at 1 day and 1, 4, and 8 weeks.

RESULTS

VA in both the diclofenac- and betamethasone-treated eyes significantly improved following the cataract surgery; however, no statistical difference of VA was noted between the diclofenac- and betamethasone-treated eyes throughout the observational period (before and after the surgery until 8 weeks postoperatively). FT in both eyes increased after the cataract surgery. FT in the diclofenac-treated eyes did not increase 1 week after surgery, but gradually increased at week 4 and week 8. In contrast, the FT in the betamethasone-treated eyes increased during 1-8 weeks postoperatively. IOP in the diclofenac-treated eyes decreased with time, but IOP in the betamethasone-treated eyes showed no change throughout the observational period.

CONCLUSIONS

Postoperative macular thickening following cataract surgery in patients with non- or mild nonproliferative-diabetic retinopathy cannot be fully suppressed by either topical diclofenac or betamethasone. Nonetheless, diclofenac protected against an early event of postoperative CME and also a decrease of IOP.

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Non-steroidal anti-inflammatory agents for treating cystoid macular oedema following cataract surgery

BACKGROUND

Cystoid macular oedema (CMO) is the accumulation of fluid in the central retina (the macula) due to leakage from dilated capillaries. It is the most common cause of poor visual outcome following cataract surgery. The exact cause is unclear. Acute CMO, defined as oedema of less than four months duration, often resolve spontaneously. CMO that persists for four months or more is termed chronic CMO. Different types of non-steroidal anti-inflammatory agents (NSAIDs) are used in the treatment of CMO which may be delivered topically or systemically.

OBJECTIVES

To examine the effectiveness of NSAIDs in the treatment of CMO following cataract surgery.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials - CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) on The Cochrane Library (Issue 2 2004), MEDLINE (1966 to April 2004), EMBASE (1980 to May 2004), LILACS (April 2004) and the reference lists of identified trials. We searched conference abstracts (sessions related to cataract) in ARVO 1975 to 2003. We contacted experts in the field and NSAIDs manufacturers for details on published and unpublished trials.

SELECTION CRITERIA

Randomised controlled trials evaluating the effects of NSAIDs in the treatment of CMO following cataract surgery.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data. Since considerable heterogeneity was observed between studies we did not conduct meta-analyses.

MAIN RESULTS

Seven trials involving a total of 266 participants were included. Four trials studied the effects of NSAIDs in chronic CMO while the other three examined the effect of NSAIDs in acute CMO. Of the studies examining chronic CMO, one study enrolled 120 participants, but the remainder had 34 or fewer participants. Four different NSAIDs were used and administered in different ways. Indomethacin was used orally and was found to be ineffective for chronic CMO in one trial. Topical fenoprofen was also found to be ineffective for chronic CMO in another small trial. Treatment with topical 0.5% ketorolac for chronic CMO was found to be effective in two trials. Three trials examined the effect of topical NSAIDs on acute CMO. The comparisons among these studies were of an NSAID to placebo, prednisolone or another NSAID. The study design differed between the studies in other important aspects thus they could not be combined in a meta-analysis.

AUTHORS' CONCLUSIONS

This review found two trials which showed that topical NSAID (0.5% ketorolac tromethamine ophthalmic solution) has a positive effect on chronic CMO. However, the effects of NSAIDs in acute CMO remains unclear and needs further investigation.

Retinal thickness measurement after phacoemulsification

PURPOSE

To measure macular thickness using the Retinal Thickness Analyzer (RTA) (Talia Technologies, Ltd.) before and after routine phacoemulsification.

SETTING

Ophthalmology Clinic, Ambulatory Care Center, University of North Carolina at Chapel Hill, School of Medicine, and the University of North Carolina Hospitals, Chapel Hill, North Carolina, USA.

METHODS

Thirty-five nonconsecutive patients scheduled for phacoemulsification and posterior chamber intraocular lens implantation were recruited. The best corrected visual acuity (BCVA) and macular thickness in the surgical and nonsurgical eyes were measured with the RTA prior to surgery and 1 and 6 weeks after surgery. Wilcoxon signed rank tests were used to evaluate each index of macular thickness--the mean posterior pole, perifoveal, and foveal thicknesses--over the 3 time periods and to compare the indices before surgery in surgical and nonsurgical eyes. Spearman correlations were computed for each index and the BCVA. Significance was assessed at the 5% level.

RESULTS

Preoperatively, all indices were higher in surgical [corrected] eyes than in nonsurgical [corrected] eyes. In surgical eyes, all indices decreased from preoperatively to 6 weeks after surgery. In nonsurgical eyes, there was no change. The BCVA in surgical eyes improved from before surgery to 1 week and 6 weeks after surgery. In surgical eyes, there were nonsignificant negative correlations between each index and the BCVA before surgery and 1 and 6 weeks after surgery. In nonsurgical eyes, there were nonsignificant negative correlations between each index and the BCVA preoperatively and 6 weeks after surgery, except for a significant negative correlation for the foveal index at 6 weeks.

CONCLUSIONS

Measurements by the RTA indicate that the decrease in macular thickness indices in surgical eyes from before surgery to 6 weeks after routine phacoemulsification is an artifact of imaging the retina through hazy media. Therefore, the results must be interpreted in the context of the clinical situation.

Treatment of acute pseudophakic cystoid macular edema: Diclofenac versus ketorolac

PURPOSE

To investigate whether topical diclofenac sodium 0.1% solution (Voltaren Ophthalmic) is as efficacious as topical ketorolac tromethamine 0.5% solution (Acular) in the treatment of established, chronic cystoid macular edema (CME) after uneventful phacoemulsification cataract extraction with posterior chamber intraocular lens (IOL) implantation.

SETTING

Referral-based vitreoretinal private practice.

METHODS

This randomized prospective study comprised 34 consecutive patients with clinical CME after uneventful phacoemulsification cataract extraction with posterior chamber IOL implantation who were referred to a private vitreoretinal practice for evaluation and management. Exclusion criteria included a history of previous intraocular surgery, vitreous loss during cataract surgery, CME, uveitis, and vitreoretinal pathology. The eye with CME was treated with 1 drop 4 times daily of diclofenac sodium 0.1% solution or ketorolac tromethamine 0.5% solution. Outcomes were measured by observing for improvement in CME and visual acuity.

RESULTS

Both treatment methods resulted in a significant reduction in CME and a significant improvement in visual acuity. Within 26 weeks, diclofenac reduced CME in 16 patients (89%) and ketorolac, in 14 patients (88%) (P =.92, confidence interval [CI] 95%). Within 26 weeks, diclofenac eliminated CME in 14 patients (78%) and ketorolac, in 12 patients (75%) (P =.86, CI 95%). The mean time to initial CME reduction was 7.5 weeks with diclofenac and 8.0 weeks with ketorolac (P =.41, CI 95%). The mean time to CME resolution was 13.6 weeks with diclofenac and 12.8 weeks with ketorolac (P =.49, CI 95%).

CONCLUSIONS

Diclofenac sodium 0.1% solution and ketorolac tromethamine 0.5% topical ophthalmic solution eyedrops were equally effective in reducing the severity and duration of CME after uneventful phacoemulsification with posterior chamber IOL implantation. Either solution may be considered for CME after cataract surgery, especially in patients who may not tolerate corticosteroid treatment.

A comparison of anterior chamber and posterior chamber intraocular lenses after vitreous presentation during cataract surgery: the Department of Veterans Affairs Cooperative Cataract Study

PURPOSE

To compare the efficacy and safety of anterior chamber (AC) intraocular lenses (IOLs) and posterior chamber (PC) IOLs implanted after vitreous presentation during extracapsular cataract extraction (ECCE).

DESIGN

The study was a prospective, long-term, randomized clinical trial conducted at 19 Department of Veterans Affairs medical centers across the United States.

METHODS

There were 438 eyes (438 patients) that met preliminary eligibility criteria, suffered vitreous presentation during ECCE (phacoemulsification or classical extracapsular technique), and had sufficient capsular support for a PC IOL without sutures after anterior vitrectomy randomized to either a PC IOL (230 patients) or an AC IOL (208 patients). Patients were examined at 3, 6, and 12 months post-surgery and yearly thereafter. Minimum follow-up was 1 year. The primary outcome measure of best-corrected visual acuity at 1 year was obtained by a masked certified examiner.

RESULTS

More PC IOL patients (91%) achieved visual acuity of 20/40 or better at 1 year than AC IOL patients (79%), a highly significant difference (P =.003). There was no significant difference between the two groups for patient's rating of vision or adverse events. Over 84% of the PC IOL patients and over 77% of the AC IOL patients rated their vision as good or better at 1 year as opposed to only 7% giving such ratings before surgery. For at least one rating period during the first year, 13.2% of the combined study patients had cystoid macular edema, 8.5% had posterior capsule opacification, 5.7% had glaucoma, and 3.7% had retinal detachment.

CONCLUSION

In the presence of sufficient capsular support, a PC IOL should be implanted after vitreous presentation during ECCE.

Comparative evaluation of corneal epithelial permeability after the use of diclofenac 0.1% and flurbiprofen 0.03% after phacoemulsification

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.

Corneal complications associated with topical ophthalmic use of nonsteroidal antiinflammatory drugs

PURPOSE

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

SETTING

Practice-based reports.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Control of intraocular inflammation associated with cataract surgery

Major advances in cataract extraction techniques and instrumentation have occurred over the past decade. Smaller incisions, more efficient phacoemulsifiers, and decreased surgical times are a few of the changes that have helped to alleviate postoperative inflammation, but postoperative inflammation continues to be a cause of patient discomfort; delayed recovery; and, in some cases, suboptimal visual results secondary to cystoid macular edema. This article reviews the most recent literature regarding the control of intraocular inflammation associated with cataract surgery.

Cystoid macular edema after phacoemulsification: relationship to blood-aqueous barrier damage and visual acuity

PURPOSE

To ascertain the incidence of cystoid macular edema (CME) after phacoemulsification and its relationship to blood-aqueous barrier damage and visual acuity.

SETTING

A British teaching hospital.

METHODS

A prospective trial was performed to document the incidence of CME after routine phacoemulsification with continuous curvilinear capsulorhexis. LogMAR visual acuity and laser flare were measured using the KOWA FC 1000 laser cell-flare meter preoperatively and 1, 14, 30, and 60 days postoperatively. At day 60, a standardized fluorescein angiogram was performed and graded by masked observers.

RESULTS

The rate of angiographic CME on day 60 was 19%. Visual acuity at each visit was significantly worse in the CME group (P < .05). The flare and cell values at days 14, 30, and 60 were higher in the CME group at day 60; however, the difference was not statistically significance (P > .05).

CONCLUSIONS

The incidence of CME after routine phacoemulsification was 19%. Patients with CME at day 60 had significantly worse visual acuity than those who did not from the first postoperative day throughout the follow-up. There was a trend for patients who had CME at day 60 to have more postoperative inflammation.

Preoperative and postoperative medications used for cataract surgery

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.