The emerging roles of topical non-steroidal anti-inflammatory agents in ophthalmology

Comparison between 0.1% Nepafenac and 1% Prednisolone Eye Drop in Postoperative Management Following Micro-incisional Cataract Surgery

Purpose

To compare the efficacy of 0.1% nepafenac and 1% prednisolone acetate eye drop in postoperative inflammation control in micro-incisional cataract surgery.

Methods

We conducted a prospective, randomized, comparative, single-blind study. All the patients underwent temporal 2.2-mm micro-incisional cataract surgery. They were randomized into two groups (group A and B). Group A received 0.1% nepafenac eye drops 4 times/day for 4 weeks and group B received 1% prednisolone acetate eye drops in tapering doses for 4 weeks after surgery. Both the groups received moxifloxacin 0.5% eye drops 4 times/day for 2 weeks. Patients were examined on 1st, 7th, and 30th postoperative days and parameters of postoperative inflammation were evaluated and noted at each visit.

Results

A total of 200 patients were enrolled in the study. However, five patients lost to follow up, group A had 97 and group B had 98 patients respectively. Results were statistically insignificant in terms of the difference in lid edema, conjunctival congestion, corneal edema, anterior chamber cells and flare between the two groups with p-values >0.05 for each parameter at each visit. However, the difference in mean central macular thickness between the groups was significant (205.713 ± 17.14 vs. 220.984 ± 32.83 in group A and B, respectively, p ≤ 0.001) at 1 month. Also, the mean pain score was significantly lower (p = 0.018) in the nepafenac group at day 7 of surgery.

Conclusions

Nepafenac is equally effective and non-inferior to prednisolone acetate in suppression and prevention of inflammation in postoperative period.

Diclofenac Versus Dexamethasone Following Strabismus Surgery: A Systematic Review and Meta-Analysis

Purpose: To compare outcomes of diclofenac versus dexamethasone in patients after strabismus surgery. Methods: A systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search was conducted on MEDLINE, EMBASE, EMCARE, CINAHL, and the Cochrane Central Register of Controlled Trials (CENTRAL). All randomized controlled trials (RCTs) comparing the outcomes of diclofenac versus dexamethasone poststrabismus surgery were included. An extraction spreadsheet for data collection and Review Manager 5.3 were used for data analysis based on the fixed and random effects models. Discomfort, inflammation, chemosis, conjunctival gap, and intraocular pressure (IOP) were primary outcome measures. Secondary outcomes included conjunctival congestion and injection, discharge, and drop intolerance. Fixed and random effects models were used for the analysis. Results: Five RCTs enrolling 248 subjects were enrolled. At week 2 postoperatively, there was a significant difference favoring diclofenac over dexamethasone in terms of discomfort (mean difference [MD] = -0.37, P = 0.02), conjunctival inflammation (MD = -0.16, P = 0.02), conjunctival chemosis (MD = -0.16, P = 0.04), and postoperative conjunctival gap (MD = -0.17, P = 0.002). In terms of IOP, there were no significant differences. However, no statistically significant differences were noted at weeks 1 and 4 postoperatively. For secondary outcomes, dexamethasone had significantly improved conjunctival congestion; however, diclofenac had significantly less injection at the site of muscle attachments at week 2. No significant difference was noted in terms of discharge and drop intolerance. Conclusion: Diclofenac is comparable to dexamethasone when used following strabismus surgery. However, a significant difference favoring diclofenac in terms of discomfort, inflammation, conjunctival chemosis, and conjunctival gap was only noted at 2 weeks postoperatively. The authors suggest conducting further studies to support the effectiveness of diclofenac as an alternative to corticosteroids following strabismus surgery.

Corticosteroids in ophthalmology: drug delivery innovations, pharmacology, clinical applications, and future perspectives

Corticosteroids remain the mainstay of the treatment for various ocular conditions affecting the ocular surface, anterior and posterior segments of the eye due to their anti-inflammatory, anti-oedematous, and anti-neovascularization properties. Prednisolone, prednisolone acetate, dexamethasone, triamcinolone acetonide, fluocinolone acetonide, and loteprednol etabonate are amongst the most widely used ophthalmic corticosteroids. Corticosteroids differ in their activity and potency in the eye due to their inherent pharmacological and pharmaceutical differences. Different routes and regimens are available for ocular administration of corticosteroids. Conventional topical application to the eye is the route of choice when targeting diseases affecting the ocular surface and anterior segment, while periocular, intravitreal, and suprachoroidal injections can be potentially effective for posterior segment diseases. Corticosteroid-induced intraocular pressure elevation and cataract formation remain the most significant local risks following topical as well as systemic corticosteroid administration. Invasive drug administration via intracameral, subconjunctival, and intravitreal injection can enhance ocular bioavailability and minimize dose and dosing frequency of administration, yet may exacerbate ocular side effects of corticosteroids. This review provides a critical appraisal of the ophthalmic uses of corticosteroid, routes of administration, drug delivery fundamentals and novel ocular implantable steroid delivery systems, factors influencing side effects, and future perspectives for ocular corticosteroid therapy.

Recent Advances in the Design of Topical Ophthalmic Delivery Systems in the Treatment of Ocular Surface Inflammation and Their Biopharmaceutical Evaluation

Ocular inflammation is one of the most common symptom of eye disorders and diseases. The therapeutic management of this inflammation must be rapid and effective in order to avoid deleterious effects for the eye and the vision. Steroidal (SAID) and non-steroidal (NSAID) anti-inflammatory drugs and immunosuppressive agents have been shown to be effective in treating inflammation of the ocular surface of the eye by topical administration. However, it is well established that the anatomical and physiological ocular barriers are limiting factors for drug penetration. In addition, such drugs are generally characterized by a very low aqueous solubility, resulting in low bioavailability as only 1% to 5% of the applied drug permeates the cornea. The present review gives an updated insight on the conventional formulations used in the treatment of ocular inflammation, i.e., ointments, eye drops, solutions, suspensions, gels, and emulsions, based on the commercial products available on the US, European, and French markets. Additionally, sophisticated formulations and innovative ocular drug delivery systems will be discussed. Promising results are presented with micro- and nanoparticulated systems, or combined strategies with polymers and colloidal systems, which offer a synergy in bioavailability and sustained release. Finally, different tools allowing the physical characterization of all these delivery systems, as well as in vitro, ex vivo, and in vivo evaluations, will be considered with regards to the safety, the tolerance, and the efficiency of the drug products.

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.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

The Efficacy of 2.5% Phenylephrine and Flurbiprofen Combined in Inducing and Maintaining Pupillary Dilatation during Cataract Surgery

Purpose

To evaluate the effectiveness of phenylephrine 2.5% and flurbiprofen 0.03% combined in inducing and maintaining mydriasis during extracapsular cataract extraction (ECCE).

Methods

One hundred patients undergoing ECCE + intraocular lens (IOL) implantation were randomly divided into four groups. The first group was given phenylphrine 10%, the second group phenylephrine 10% + flurbiprofen, the third group phenylephrine 2.5% and fourth group phenylephrine 2.5% + flurbiprofen. Cyclopentolate 1% was used in all patients. Phenylephrine and cyclopentolate were instilled preoperatively four times during 1 hour and flurbiprofen was given four times the day before surgery and twice with an hour's interval before operation. Pre-operative and post-cortex aspiration horizontal pupil diameters were measured with callipers viewed through the operating microscope.

Results

Pupil diameters in pre-operative and post-cortex aspiration were no different in the 2.5% and 10% phenylephrine groups (p>0.05). Both diameters were larger and pupillary constriction was smaller in the flurbiprofen groups (p<0.05).

Conclusions

2.5% phenylephrine was as effective as 10% phenylephrine, with and without flurbiprofen, in inducing and maintaining pupil dilatation during ECCE surgery.

Bromfenac ophthalmic solution 0.09 %: human aqueous humor concentration detected by high-performance liquid chromatography

The purpose of this study was to evaluate the aqueous humor concentrations of bromfenac ophthalmic solution 0.09 % in patients undergoing phacoemulsification. Patients requiring cataract extraction received one drop (50 µL) of bromfenac 0.09 % solution in the eye to be operated, before bedtime the day before surgery or the morning of the surgery. The last administration was recorded. At the time of paracentesis, an aqueous humor sample was collected with a 30-gauge needle attached to a TB syringe and was later analyzed by high-performance liquid chromatography for drug concentration. 188 treated volunteers and 48 control, untreated, subjects were included in the study. The mean aqueous concentration of bromfenac in the treated group was 37.60 ± 68.86 and 0 nM (nmol/L) in the control group (p < 0.0001). Correlation coefficient in bromfenac group between time elapsed from instillation and drug concentration was -0.16 (p not significant). Bromfenac showed properties of good penetration and stable concentration in aqueous humor up to about 12 h after instillation.

The clinical utility of new combination phenylephrine/ketorolac injection in cataract surgery

The maintenance of mydriasis throughout cataract extraction surgery and the control of ocular inflammation are crucial for successful surgical outcomes. The development of miosis during cataract surgery compromises the visualization of the surgical field and working space for surgeons. This may lead to complications that include posterior capsular tear and associated vitreous loss, longer surgical time, and postoperative inflammation. Postoperative inflammation is often uncomfortable and frustrating for patients. It causes pain, redness, and photophobia. This compromises the best-uncorrected vision following surgery and often leads to multiple clinic visits. This article examines the literature published on the current treatments used to manage mydriasis, pain, and inflammation in cataract extraction surgery. Combination phenylephrine/ketorolac injection offers an exciting new class of medication for use in cataract surgery. With the recent approval of Omidria™ (combination of phenylephrine 1% and ketorolac 0.3%) by the US Food and Drug Administration (FDA) for intraocular use, we review the clinical utility of this new combination injection in cataract surgery. PubMed, MEDLINE, and conference proceedings were searched for the relevant literature using a combination of the following search terms: cataract extraction surgery, pupil dilation (mydriasis), miosis, phenylephrine, ketorolac, Omidria™, intracameral mydriatic. Relevant articles were reviewed and their references checked for further relevant literature. All abstracts were reviewed and full texts retrieved where available.

Management of mydriasis and pain in cataract and intraocular lens surgery: review of current medications and future directions

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.

The efficacy of bromfenac ophthalmic solution 0.07% dosed once daily in achieving zero-to-trace anterior chamber cell severity following cataract surgery

Purpose

To evaluate the efficacy of bromfenac ophthalmic solution 0.07% dosed once daily in achieving zero-to-trace (0–5 cells) anterior chamber cells, following cataract surgery with posterior chamber intraocular lens implantation.

Methods

The study designed employed two Phase III, double-masked, placebo-controlled, multicenter clinical trials of 440 subjects, randomized to either bromfenac ophthalmic solution 0.07% (n=222) or placebo (n=218). Subjects self-dosed once daily, beginning 1 day before undergoing cataract surgery with intraocular lens implantation (day –1) and again on the day of surgery (day 0) and for 14 days postoperatively. Follow-up was on days 1, 3, 8, and 15. The outcome measures included the percentage of subjects with zero-to-trace anterior chamber cells at each visit, as determined by the percentage of subjects with ≤5 anterior chamber cells, overall anterior chamber cell grades, and summed ocular inflammation score (SOIS) (combined anterior chamber cell and flare scores).

Results

The proportion of subjects with zero-to-trace anterior chamber cells was significantly higher in the bromfenac 0.07% group compared with the placebo group as early as day 3 (P=0.0007), continued at day 8 (P<0.0001), and through day 15 (P<0.0001). At day 15, 80.2% of subjects in the bromfenac 0.07% group achieved zero-to-trace anterior chamber cells compared with 47.2% of subjects who did so in the placebo group. The overall anterior chamber cell scores were significantly lower in the bromfenac 0.07% group compared with the placebo group at days 3, 8, and 15 (P<0.0001 at each visit). The SOIS were also significantly lower in the bromfenac group compared with the placebo group at days 3, 8, and 15 (P<0.0001 at each visit).

Conclusion

Bromfenac ophthalmic solution 0.07%, dosed once daily was clinically effective in achieving zero-to-trace anterior chamber cell severity after cataract surgery and was superior to placebo in all anterior chamber cell severity and inflammation outcome measures.

Bromfenac ophthalmic solution for the treatment of postoperative ocular pain and inflammation: safety, efficacy, and patient adherence

Ophthalmic nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used by clinicians to manage ocular inflammation and pain following cataract surgery. Over the past decade, the US Food and Drug Administration has approved multiple topical NSAIDs for these purposes, including several reformulated products. One of these medications, bromfenac ophthalmic solution, has a long and extensive history, with proven efficacy and safety in patients following cataract surgery. The evolution of bromfenac ophthalmic solution over the years has involved either lowering the concentration of the active ingredient or extending the dosing interval to improve patient adherence/compliance. This review will focus on the history and progression of bromfenac ophthalmic solution and report the available patient preference and adherence data regarding this ocular NSAID throughout its evolution.

Prostaglandin E2 inhibition of ketorolac 0.45%, bromfenac 0.09%, and nepafenac 0.1% in patients undergoing phacoemulsification

INTRODUCTION

We compared the prostaglandin E(2) (PGE(2)) inhibition of three topical nonsteroidal antiinflammatory drugs (NSAIDs): ketorolac 0.45%, bromfenac 0.09%, and nepafenac 0.1% at peak dosing levels in patients previously scheduled to undergo phacoemulsification.

METHODS

This was a single-center, double-masked observational study of 121 patients randomized to one of three NSAID treatment arms. Patients were instructed to take the NSAID per on-label dosing (twice daily [b.i.d.] for ketorolac 0.45% and bromfenac 0.09%, three times a day [t.i.d.] for nepafenac 0.1%) for 1 day before surgery, and were to instill one drop the morning of surgery. Each patient received an additional four doses 1 hour prior to undergoing phacoemulsification. After completion of the paracentesis site with a super blade, aqueous humor (0.15 mL) was collected through the peripheral clear cornea with a 30 G needle attached to a tuberculin (TB) syringe. Aqueous humor samples were stored at -40°C prior to analysis, and diluted 1:10 with diluent. Assays were conducted on multiple plates in duplicate (seven standards per plate).

RESULTS

The mean (±SD) PGE(2) concentrations were 224.8±164.87 pg/mL for ketorolac 0.45% (n=42), 288.7±226.05 pg/mL for bromfenac 0.09% (n=41), and 320.4±205.6 pg/mL for nepafenac 0.1% (n=38). The difference between ketorolac 0.45% and nepafenac 0.1% was statistically significant (P=0.025). The difference between bromfenac 0.09% and nepafenac 0.1% was not significantly different (P=0.516).

CONCLUSIONS

Ketorolac 0.45% achieved the greatest inhibition of PGE(2) compared to nepafenac 0.1% and bromfenac 0.09%. Ketorolac 0.45% may be more efficacious at controlling inflammation at the time of cataract surgery versus nepafenac 0.1% and bromfenac 0.09%.

A randomized comparison of to-aqueous penetration of ketorolac 0.45%, bromfenac 0.09% and nepafenac 0.1% in cataract patients undergoing phacoemulsification

OBJECTIVE

To compare the peak to-aqueous penetration of three nonsteroidal anti-inflammatory drugs: ketorolac tromethamine 0.45%, bromfenac 0.09%, nepafenac 0.1%, and amfenac (the active metabolite of nepafenac) in patients undergoing phacoemulsification.

METHODS

A single center, double-masked study randomized 122 patients to receive one of three treatment arms. On-label dosing of ketorolac (BID), bromfenac (BID), and nepafenac (TID) was instructed for 1 day prior to surgery. Patients were instructed to instill one drop the morning of surgery. The patients received four additional doses 1 hour prior to phacoemulsification. After completion of the paracentesis site with a superblade, aqueous humor (0.15 cc) was collected through the peripheral clear cornea with a 30-gauge needle attached to a TB syringe. Following collection, aqueous samples were stored at -40°C prior to analysis. Drug concentrations were analyzed by liquid chromatography tandem mass spectrometry using positive turbo-ion spray ionization and multiple reaction monitoring mode for quantification. An independent sample Student's t-test was used to detect between-group differences.

RESULTS

The peak aqueous concentration of ketorolac 0.45% was 10 times the concentration of bromfenac 0.09%, and five times the concentration of and 54% greater than the metabolically inactive nepafenac 0.1%. The mean peak aqueous concentration of ketorolac 0.45% was 688.87 ± 749.6 ng/ml. Bromfenac achieved a mean peak aqueous concentration of 67.64 ± 62.4 ng/ml. The mean peak aqueous concentrations of nepafenac and amfenac were 447.10 ± 225.7 ng/ml and 140.37 ± 56.6 ng/ml, respectively. The peak concentration of ketorolac was statistically significantly greater than bromfenac (P ≤ 0.0005), nepafenac (P ≤ 0.05), and amfenac (P ≤ 0.005). A limitation of this study is that aqueous samples were collected just prior to surgery and not during the postoperative period due to ethical considerations.

CONCLUSIONS

Ketorolac 0.45% achieved significantly greater aqueous concentrations when compared to bromfenac 0.09% and the active metabolite of nepafenac 0.1% (amfenac) in patients undergoing phacoemulsification.

Comparison of ocular tolerability between preserved and preservative-free diclofenac sodium drops

PURPOSE

To compare the tolerability of preserved diclofenac sodium 0.1% (Voltaren Ophtha) and preservative-free diclofenac (Dicloftil).

METHODS

Thirty healthy volunteers received a single drop of Voltaren Ophtha in 1 eye, and a single drop of Dicloftil in the other. Both drops were instilled at the same time, in a single-blind manner. Visual analog scale grading was used to measure ocular discomfort, itch, burn, and pain. Grading was obtained before drop instillation and after 15 s, 1 min, 5 min, 15 min, and 30 min.

RESULTS

Both preparations caused discomfort, itch, burn, and pain, with a peak effect on all 4 parameters at 15 min. However, preservative-free Dicloftil proved to be more tolerable than preserved Voltaren Ophtha. Data show significantly lower reported levels of discomfort and itch up to 15 min, lower levels of burn at the first minute, and less pain immediately after instillation.

CONCLUSION

This is the first study to compare subjective ocular tolerability of a single drop. Our results indicate that Dicloftil has better tolerability than Voltaren Ophtha. Ophthalmologists should be aware of this significant difference when prescribing diclofenac, especially in patients with low compliance or who require prolonged therapy.

Ex vivo corneal epithelial wound healing following exposure to ophthalmic nonsteroidal anti-inflammatory drugs

Purpose:

Ketorolac 0.45% is a new formulation of topical ketorolac in which preservative (benzalkonium chloride, BAK) was removed and carboxymethylcellulose (CMC) was added to improve tolerability and reduce dosing frequency. This study compared the effects of ketorolac 0.45% on corneal wound healing to prior ketorolac formulations (0.4% and 0.5%), bromfenac 0.09%, and nepafenac 0.1%.

Methods:

Two parallel-group comparisons were performed in series. A 5-mm central epithelial wound was made in fresh porcine corneas. After 24 hours in minimum essential medium (MEM), corneas were incubated for 10 minutes with study drugs, Triton X-100 1% (positive control), or MEM (negative control), followed by 24 hours in MEM. The remaining wound area was stained, photographed, and quantified (pixels). Study 1 compared ketorolac 0.45% to ketorolac 0.4% and ketorolac 0.5%. Study 2 compared ketorolac 0.45% to bromfenac 0.09% and nepafenac 0.1%.

Results:

The mean (±SD) original wound area was 200,506 ± 4,363 pixels, which was reduced to 59,509 ± 4850 at 48 hours after exposure to Triton X-100 1%. In study 1, the mean remaining wound areas at 48 hours in pixels were 2969 ± 1633 with MEM, 586 ± 299 with ketorolac 0.45% (significantly reduced, P < 0.05 vs all other treatments), 10,228 ± 7541 with ketorolac 0.4%, and 50,674 ± 33,409 with ketorolac 0.5% (significantly enlarged, P < 0.05 vs MEM). In study 2, the mean remaining wound areas at 48 hours were 565 ± 1263 with MEM, 322 ± 229 with ketorolac 0.45% (significantly reduced, P < 0.01 vs bromfenac 0.09% and nepafenac 0.1%), 29,093 ± 14,295 with bromfenac 0.09% (significantly enlarged, P <0.01 vs MEM) and 47,322 ± 13,736 with nepafenac 0.1% (significantly enlarged, P < 0.01 vs MEM and vs bromfenac 0.09%).

Conclusion:

Corneas treated with ketorolac 0.45% healed as rapidly as those treated with MEM, likely secondary to addition of CMC and removal of BAK. In the ex vivo corneal organ culture model, ketorolac 0.45% had statistically less impact on corneal re-epithelialization than prior ketorolac formulations (0.4% and 0.5%), bromfenac 0.09%, and nepafenac 0.01%.

Comparison of Ketorolac Tromethamine and Prednisolone Acetate in Preventing Surgically Induced Miosis during Cataract Surgery

OBJECTIVES

The aim of this study was to compare the efficacy and safety of topical prednisolone acetate 1% and topical ketorolac tromethamine 0.5% in the maintenance of pupillary mydriasis during cataract surgery.

METHODS

Fifty patients were enrolled in this prospective, partially masked and randomised study. They were assigned to receive topical treatment with either prednisolone acetate (n = 25) or ketorolac tromethamine (n = 25), starting 24 hours before cataract extraction (either routine extracapsular cataract extraction or phacoemulsification). One drop of the study medication was instilled every 6 hours for a total of 4 drops. No epinephrine was used in the intraoperative irrigation solution. Pupil diameter was measured three different times during surgery. To ensure participant safety, biomicroscopy, ophthalmoscopy, intraocular pressure, adverse events and visual acuity were also monitored.

RESULTS

The mean pupil diameter change from the time of the pre-incision until after cortical irrigation and aspiration and lens implantation was significantly less with ketorolac than with prednisolone (P = 0.003). Consequently, mean pupil diameter after cortical irrigation and aspiration and lens implantation was significantly greater with ketorolac than with prednisolone (P <0.0001). No significant differences between groups were observed in the pupil diameter before the first incision (P = 0.244), nor after administration of a miotic agent (P = 0.505). Safety variables were comparable and no drug-related adverse events were reported.

CONCLUSION

Ketorolac tromethamine 0.5% and prednisolone acetate 1% solutions were equally well tolerated without related adverse events, but ketorolac was better in preventing surgically induced miosis.

Aqueous prostaglandin E(2) of cataract patients at trough ketorolac and bromfenac levels after 2 days dosing

INTRODUCTION

Ketorolac 0.4% administered four times daily (q.i.d.) has long been used safely and effectively for the alleviation of ocular inflamation and pain and the prevention of intraoperative miosis in patients undergoing cataract surgery. Bromfenac ophthalmic solution 0.09% was recently developed as an ocular anti-inflammatory drug with a twice-daily (b.i.d.) dosing regimen. This study was designed to evaluate if b.i.d. dosing with bromfenac 0.09%, in comparison with q.i.d. dosing with ketorolac 0.4%, provides adequate trough nonsteroidal anti-inflammatory drug levels that were effective enough to reduce aqueous prostaglandin (PG) E(2) levels of patients after cataract surgery toward the end of its dosing cycle.

METHODS

In this single-center, investigator-masked trial, patients undergoing cataract surgery were randomized to receive either ketorolac 0.4% q.i.d. or bromfenac 0.09% b.i.d. for 2 days preoperatively. Aqueous humor was collected at the start of surgery 6 hours after the last dose of ketorolac 0.4% and 12 hours after the last dose of bromfenac 0.09%. Aqueous PGE(2) levels and drug concentrations were evaluated by a competitive enzyme immunoassay and reverse-phase HPLC-mass spectroscopy, respectively.

RESULTS

A total of 61 patients received ketorolac 0.4% (n=30) or bromfenac 0.09% (n=31). The mean (+/-SD) aqueous PGE(2) level was 285.6+/-141.9 pg/mL in patients treated with ketorolac 0.4% and 386.2+/-131.0 pg/mL in patients treated with bromfenac 0.09% (P=0.006). The mean (+/-SD) aqueous concentrations of ketorolac and bromfenac were 83.6+/-73.8 ng/mL and 9.2+/-6.6 ng/mL, respectively (P<0.001).

CONCLUSIONS

Ketorolac 0.4% maintained significantly higher aqueous concentrations and lowered aqueous PGE(2) levels significantly more than bromfenac 0.09% at trough levels. Ketorolac 0.4% administered q.i.d. may provide a more sustained control of intraocular inflammation and pain than bromfenac 0.09% administered b.i.d.

Oral versus topical diclofenac for pain prevention during panretinal photocoagulation

PURPOSE

To investigate the effect of pretreatment oral and topical diclofenac on pain reduction during panretinal laser photocoagulation (PRP) for proliferative diabetic retinopathy (PDR).

DESIGN

Prospective, randomized, double-masked, placebo-controlled clinical trial.

PARTICIPANTS AND CONTROLS

A total of 90 patients with PDR requiring PRP for the first time were assigned randomly to 1 of 3 study groups: oral diclofenac (n = 30), topical diclofenac (n = 31), or placebo (n = 29).

METHODS

Study medications were administrated before the first PRP treatment, and pain levels experienced during and 15 minutes after PRP were recorded on a visual analog scale (VAS). Pain levels during a second PRP session, performed on a later date with no pretreatment medications, also were recorded on a VAS.

MAIN OUTCOME MEASURES

The primary outcome measures were the mean VAS pain scores during the first PRP treatment. Secondary outcome measures were the mean VAS pain scores 15 minutes after the first PRP and during the second PRP, and reported side effects after the first PRP.

RESULTS

Mean VAS pain scores during the first PRP were: oral diclofenac, 25.7+/-19.9; topical diclofenac, 33.8+/-27.9; and placebo, 41.3+/-31.0. The pain score difference between oral diclofenac and placebo was both clinically significant (>or=13) and statistically significant (P = 0.02), whereas differences between oral and topical diclofenac (P = 0.20) and topical diclofenac and placebo (P = 0.33) were not. Multivariate regression analysis for age, gender, and total laser energy demonstrated lower pain levels for both oral diclofenac (P = 0.015) and topical diclofenac (P<0.0001) versus placebo, but no difference between oral and topical diclofenac (P = 0.67). For the first PRP, all 3 groups had lower mean pain scores at 15 minutes after treatment compared with during treatment (P<or=0.0003). Mean pain scores were higher during the second compared with the first PRP for the oral diclofenac (P = 0.02) and placebo (P = 0.05) groups. No significant rate difference for any side effect was found between groups.

CONCLUSIONS

When given in a single dose, oral diclofenac is an effective pretreatment analgesic agent for reducing the pain experienced during PRP for PDR.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

The role of NSAIDs in the management of postoperative ophthalmic inflammation

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

Comparison of cyclooxygenase inhibitory activity and ocular anti-inflammatory effects of ketorolac tromethamine and bromfenac sodium

OBJECTIVE

To compare the cyclooxygenase (COX) activity and anti-inflammatory effects of the nonsteroidal anti-inflammatory drugs (NSAIDs) ketorolac tromethamine (ketorolac) and bromfenac sodium (bromfenac).

METHODS

Cyclooxygenase activity and selectivity was determined in vitro by measuring prostaglandin E(2) (PGE(2)) production following incubation of varying concentrations of NSAID with human recombinant COX-1 or COX-2 and arachidonic acid. Anti-inflammatory effects were evaluated in a rabbit model in which an ocular inflammatory response was induced by intravenous injection of 10 microg/kg lipopolysaccharide (LPS). In study animals, one eye was treated with 50 microL (+/-) ketorolac 0.4% (Acular LS) or bromfenac 0.09% (Xibrom) and the other eye with 50 microL buffered saline. In control animals, both eyes were treated with vehicle. All animals were treated twice: 2 hours and 1 hour before LPS.

MAIN OUTCOME MEASURES

PGE(2) production in vitro, measured by enzyme immunoassay; fluorescein isothiocyanate (FITC)-dextran leakage into the anterior chamber, measured by fluorophotometry; aqueous PGE(2) levels in vivo, measured by ELISA immunoassay.

RESULTS

Ketorolac was six times more active against COX-1 (IC(50) = 0.02 microM) than COX-2 (IC(50) = 0.12 microM) while bromfenac was approximately 32 times more active against COX-2 (IC(50) = 0.0066 microM) than COX-1 (IC(50) = 0.210 microM). In the animal model, both drugs resulted in nearly complete inhibition of FITC-dextran leakage and PGE(2) production in the anterior chamber of treated eyes. There was also a 79% inhibition (p < 0.001) of FITC-dextran leakage in the contralateral eyes of bromfenac-treated rabbits, and a 22.5% inhibition (not statistically significant) in the contralateral eyes of ketorolac-treated rabbits.

CONCLUSIONS

Ketorolac is relatively COX-1 selective while bromfenac is potently selective for COX-2 over COX-1. In the animal model, both ketorolac 0.4% and bromfenac 0.09% demonstrated maximal anti-inflammatory activity in treated eyes. Only bromfenac 0.09% had a significant effect on the contralateral eye, suggesting possible systemic absorption of this drug.

The effects of topical ketorolac and indomethacin on measles conjunctivitis: randomized controlled trial

PURPOSE

To compare the effect of topical ketorolac and indomethacin on measles conjunctivitis.

DESIGN

Prospective double-masked placebo-controlled randomized trial.

METHODS

Sixty-two patients with severe measles conjunctivitis were included in this study. All patients were hospitalized and randomly assigned to receive ketorolac 0.5% or indomethacin 0.1% in the right eye and artificial tears in the left eye. Conjunctival hyperemia, burning sensations, foreign-body sensations, and photophobia scores were conducted at baseline and at days seven and 14. A satisfaction score was evaluated at the end of the study.

RESULTS

The conjunctival injection score of the control eyes was significantly higher than those of the ketorolac- and indomethacin-treated eyes at day seven (P < .05). The conjunctival injection score of the ketorolac-treated eyes was lower than that of the indomethacin-treated eyes at days seven and 14, but this did not reach statistical significance. There was no significant difference in the burning and foreign-body sensations and in the photophobia scores among the study eyes at baseline, day seven, and day 14 (P > .05). There was no significant difference in the satisfaction score among the study eyes at the end of the study (P > .05).

CONCLUSIONS

In patients with measles during the first two weeks of infection, ketorolac and indomethacin were more effective than artificial tears in decreasing conjunctival hyperemia, but burning sensations, foreign-body sensations, and photophobia were unaffected.

Locally administered ocular corticosteroids: benefits and risks

Corticosteroids, used prudently, are one of the most potent and effective modalities available in the treatment of ocular inflammation. However, they can produce a plethora of adverse ocular and systemic events. In order to optimise and target drug delivery, whilst minimising systemic adverse effects, a diverse range of local ophthalmic preparations and delivery techniques have been developed. Topical drops and ointments remain the primary methods for administration of ocular corticosteroids. However, ocular penetration of topical corticosteroid drops depends upon drug concentration, chemical formulation of corticosteroid, and composition of the vehicle, therefore, apparently small modifications in preparations can produce a more than 20-fold difference in intraocular drug concentration. Periocular injections of corticosteroids continue to have a useful, but limited, therapeutic role and longer acting, intraocular delayed-release devices are in early clinical studies. Although newer corticosteroids with lesser pressure elevating characteristics have been developed, corticosteroid-induced ocular hypertension and glaucoma continue to be significant risks of local and systemic administration. Posterior subcapsular cataract, observed following as little as 4 months topical corticosteroids use, is thought to be due to covalent binding of corticosteroid to lens protein with subsequent oxidation. Inappropriate use of topical corticosteroid in the presence of corneal infections also continues to be a cause of ocular morbidity. Other risks of locally administered ophthalmic corticosteroids include: tear-film instability, epithelial toxicity, crystalline keratopathy, decreased wound strength, orbital fat atrophy, ptosis, limitation of ocular movement, inadvertent intraocular injection, and reduction in endogenous cortisol. This extensive review assesses the therapeutic benefits of locally administered ocular corticosteroids in the context of the risks of adverse effects.

Topical naproxen sodium for inhibition of miosis during cataract surgery. Prospective, randomized clinical trials

PURPOSE

To assess corneal penetration of naproxen sodium and its efficacy in maintaining intraoperative mydriasis during cataract surgery.

METHODS

Two double blind studies have been performed comparing the efficacy of naproxen ophthalmic solution to that of placebo or diclofenac in inhibiting pre-operative miosis. Study No. 1 was a placebo-controlled study and involved 194 patients undergoing extracapsular cataract extraction. Study No. 2 was an active-controlled study (vs diclofenac) concerning 214 patients undergoing phacoemulsification. In both studies treatment started the day before surgery. A balanced salt solution containing adrenaline was used in all patients. Pupil size was measured prior to the corneal section and at the end of surgery. An aqueous humor sample was taken immediately before corneal incision in a subset of 20 patients to measure naproxen aqueous concentration.

RESULTS

In both studies the pupillary diameter decreased during surgery within each treatment group in a statistically significant manner (P < 0.001). Naproxen was more effective than placebo (P < 0.01) and as effective as diclofenac in controlling pupil diameter regression during cataract. Mean concentration level of naproxen in the aqueous humor was 372.3 ng/ml.

CONCLUSIONS

Naproxen sodium ophthalmic solution penetrates the cornea and it is effective in maintaining intraoperative mydriasis.

Naproxen ophthalmic solution to manage inflammation after phacoemulsification

PURPOSE

To explore the efficacy and safety of 2 concentrations (0.1% and 0.2%) of sodium naproxen ophthalmic solution in controlling ocular inflammation in patients having phacoemulsification and intraocular lens implantation.

SETTING

Service d'Ophtalmologie La Pitie' and Centre Ophtalmologique, Paris, and Clinique Sourdille, Nantes, France; Department of Ophthalmology, University of Lausanne, Switzerland.

METHODS

One hundred one patients were randomly treated with naproxen 0.1%, naproxen 0.2%, or diclofenac 0.1% 3 times a day for 30 days starting the day before surgery. Postsurgical ocular inflammation was measured after 1, 10, and 30 days using the Kowa FC-1000 laser flare-cell meter and a conventional slitlamp biomicroscope. Safety parameters were evaluated at the same visits.

RESULTS

Naproxen 0.2% ophthalmic solution and diclofenac 0.01% were comparable in controlling postsurgical inflammation. The naproxen was well tolerated. No serious adverse events occurred during the study.

CONCLUSIONS

These preliminary results suggest that naproxen ophthalmic solution may be effectively and safely used to control inflammation after uneventful phacoemulsification. Because of the limited number of patients, larger studies are needed to confirm these results.

Analgesic effect of topical sodium diclofenac 0.1% drops during retinal laser photocoagulation

AIMS

To evaluate the analgesic effect of topical sodium diclofenac 0.1% during retinal laser photocoagulation.

METHODS

87 patients, 45 with proliferative diabetic retinopathy treated with two sessions of panretinal photocoagulation (group A), and 42 patients with non-proliferative diabetic retinopathy who underwent grid treatment of the posterior pole (19 bilaterally) (group B). Sodium diclofenac 0.1% or sodium chloride 0.9% drops were topically applied 30-135 minutes before laser treatment in a masked fashion. Patients who had two sessions were given the alternate drug in the second one. Pain level was evaluated immediately after laser treatment with the visual analogue scale (VAS). The results were statistically analysed.

RESULTS

Patients in group A reported pain in 85/90 sessions (94%). The average pain level was 44.2% with sodium diclofenac 0.1% drops and 53.1% with sodium chloride 0.9% drops (p = 0.011 by paired t test). Patients in group B reported pain in only 16/60 sessions (26. 7%), and the pain level ranged from 10% to 60% regardless of the kind of drops used. There was no correlation in either group between level of pain and time interval from application of the drops to laser treatment (30-135 minutes) or average energy level used (100-500 mW).

CONCLUSION

Sodium diclofenac 0.1% is useful for pain reduction and should be applied before panretinal photocoagulation.

Comparison of the efficacy and safety of ketorolac tromethamine 0.5% and prednisolone acetate 1% after cataract surgery

PURPOSE

To compare the anti-inflammatory and analgesic efficacy and safety of ketorolac tromethamine 0.5% ophthalmic solution with those of prednisolone acetate 1% in patients having cataract surgery.

SETTING

Shawnee Mission Eye Care, Shawnee Mission, Kansas, USA.

METHODS

This double-blind, randomized, single-site study comprised 59 healthy men and women with a clinical diagnosis of routine ocular cataract requiring surgical removal. All patients had extracapsular cataract extraction and posterior chamber intraocular lens implantation. After surgery, patients were randomized to receive ketorolac tromethamine 0.5% or prednisolone acetate 1%, self-instilled in the treated eye, according to the following schedule: 1 to 2 drops 4 times daily (week 1); 3 times daily (week 2); 2 times daily (week 3); once daily (week 4). Patients were examined postoperatively on days 1, 7, and 28. Intraocular anti-inflammatory efficacy was assessed by lid edema, lid injection, conjunctival injection, corneal edema, ciliary flush, and anterior chamber cells. Analgesic efficacy was assessed by patient self-rated pain severity, pain frequency, total symptom sum, and overall global improvement.

RESULTS

Both treatments produced comparable reductions in intraocular inflammation and pain after cataract surgery and were well tolerated by patients. No adverse events were reported, and there were no significant changes in intraocular pressure in either group. Improvements in visual acuity were also similar in both groups.

CONCLUSION

Ketorolac tromethamine 0.5% ophthalmic solution was as effective and well-tolerated as prednisolone acetate 1% solution in controlling postoperative inflammation and pain after cataract surgery.

Efficacy and safety profile of ketorolac 0.5% ophthalmic solution in the prevention of surgically induced miosis during cataract surgery

This multicenter, double-masked, randomized, parallel study compared the efficacy and safety profile of ketorolac tromethamine 0.5% ophthalmic solution with that of its vehicle in the maintenance of pupillary mydriasis during cataract surgery. A total of 176 adult patients scheduled to undergo unilateral extracapsular cataract extraction and posterior-chamber intraocular lens implantation received either ketorolac tromethamine 0.5% (n = 89) or vehicle (n = 87), starting 2 hours before surgery. One drop of study medication was instilled every 30 minutes for a total of 4 drops. No epinephrine was used in the intraoperative irrigating solution. Pupil diameter was measured with a caliper at 3 time points during surgery. To ensure participant safety, biomicroscopy, ophthalmoscopy, intraocular pressure, adverse events, and preoperative and postoperative visual acuity and refractive error were also monitored. The mean change in horizontal and vertical pupil diameter from the time of the first incision to after cortical irrigation and aspiration was significantly less with active ketorolac than with vehicle (P < or = 0.014). Consequently, mean pupil diameter after cortical irrigation and aspiration was significantly greater with ketorolac than with vehicle (P < or = 0.030). No significant between-group differences were observed in the change in pupil diameter between the end of surgery and postoperative administration of a miotic agent, safety variables, or occurrence of adverse events. In this study, ketorolac tromethamine 0.5% ophthalmic solution provided effective and well-tolerated inhibition of surgically induced miosis during cataract surgery.

Ketorolac tromethamine 0.5% ophthalmic solution in the treatment of moderate to severe ocular inflammation after cataract surgery: a randomized, vehicle-controlled clinical trial

PURPOSE

To investigate the efficacy and safety of ketorolac tromethamine 0.5% ophthalmic solution (Acular; Allergan, Inc, Irvine, California) in the treatment of moderate to severe anterior segment inflammation developing after unilateral cataract surgery with intraocular lens implantation.

METHODS

Only patients who exhibited moderate or greater levels of cells and flare 1 day after surgery were included in this multicenter, double-masked, randomly assigned, parallel-group study. Topical ketorolac or vehicle solution (Allergan, Inc) was administered to the treated eye four times daily, starting the day after surgery and continuing for 14 days.

RESULTS

Ketorolac was significantly more effective than the vehicle solution in reducing anterior chamber cells (P < or = .030) and flare (P < or = .025), conjunctival erythema (P < or = .046), ciliary flush (P < or = .006), tearing (P < or = .012), photophobia (P < or = .014), and pain (P < or = .049). Half as many patients from the ketorolac group (14/51) were discontinued from the study for lack of efficacy, compared with the vehicle group (28/51; P = .005). There was no significant difference between ketorolac and the vehicle solution in changes in visual acuity, intraocular pressure, biomicroscopic or ophthalmoscopic variables, or adverse events.

CONCLUSIONS

Ketorolac tromethamine 0.5% ophthalmic solution is safe and provides substantial anti-inflammatory activity in the treatment of moderate to severe anterior segment inflammation developing after cataract surgery and intraocular lens implantation.

Efficacy and safety of nonpreserved ketorolac ophthalmic solution in postoperative ocular pain following radial keratotomy

PURPOSE

To investigate the efficacy and safety of nonpreserved ketorolac tromethamine 0.5% ophthalmic solution in relieving pain following radial keratotomy (RK).

SETTING

Multicenter clinical trial.

METHODS

Topical ketorolac was compared with its vehicle in a double-masked, randomized, parallel-group study involving 170 RK patients. Patients were treated with nonpreserved ketorolac 0.5% ophthalmic solution or the vehicle 4 times daily beginning immediately after surgery and continuing for 3 days or until they no longer had ocular pain.

RESULTS

At several intervals, patients treated with ketorolac reported significantly greater pain relief and less pain intensity than patients treated with the vehicle. The time required for patients to first report "complete relief" or "no pain" was shorter in the ketorolac than in the vehicle group (P < or = .006). Patients in the ketorolac group used less escape medication (acetaminophen) (P < or = .001) and had fewer sleep difficulties (P < or = .031), fewer symptoms of ocular discomfort (P < or = .028), and less difficulty performing activities of daily living (P = .048). Patients treated with ketorolac experienced the same low rate of treatment-related adverse events as those treated with the vehicle and exhibited the same improvement in visual acuity and manifest refraction.

CONCLUSIONS

Nonpreserved ketorolac tromethamine 0.5% ophthalmic solution was significantly more effective than, and as safe as, the vehicle in alleviating the postoperative pain associated with RK. This resulted in significant improvements in patient quality of life and less need for oral analgesics, suggesting that topical ketorolac is an appropriate treatment option for ocular pain following RK.

Topical NSAIDs for musculoskeletal conditions. A review of the literature

In recent years a growing number of topical nonsteroidal anti-inflammatory drugs (NSAIDs) have become available. This has been prompted in large part by the high incidence of serious gastrointestinal adverse events associated with the use of systemic NSAIDs, and the premise that minimisation of plasma concentrations of active drug may result in fewer systemic adverse effects. Evidence in humans and animals with topical NSAIDs demonstrates lower plasma concentrations than with systemically administered drugs, while those in soft tissues are still of a magnitude considered consistent with exerting an anti-inflammatory effect. In joints, however, the evidence is less strong, and there is still dispute whether in this case the drug reaches the joint predominantly via the transcutaneous or systemic route. There has been a sufficient number of studies of soft tissue conditions to demonstrate the superiority of topical NSAIDs over placebo and to suggest equivalent efficacy in comparison with some oral NSAIDs. For arthropathies, however, the literature is more sparse. Although several studies claim a benefit for topical NSAIDs against placebo, the results are less conclusive and further study is required. Trials of topical agents against intra-articular corticosteroids and rubefacients are either lacking or inconclusive. The adverse event profile of topical agents is reasonable: minor cutaneous effects occur in up to 2% of patients but tend to be self-limiting. Gastrointestinal events appear from the existing literature to be infrequent and minor, although long term studies are required. Bronchospasm and renal impairment have been reported and may be more frequent in patients who have experienced these effects with oral agents. The initial costs of topical agents tend to be higher than those of oral agents but a cost-effectiveness analysis suggests an overall benefit: this issue requires further clarification.

Visual outcome and progression of retinopathy after cataract surgery in diabetic patients

PURPOSE

Diabetes mellitus is a major cause of visual impairment in developed countries through retinopathy and is frequently complicated by cataract formation. The present study examines the visual outcome of cataract surgery in diabetic pat ents.

METHODS

A retrospective study was performed over a 26 month period in a general hospital eye clinic. Eighty-five consecutive diabetic patients who underwent cataract surgery were categorized according to their type of diabetes, duration and treatment, operative technique, pre-operative visual acuity (VA) and degree of retinopathy. Visual acuity and retinopathy status were recorded at a minimum of 4 months postoperatively. Factors affecting visual outcome and progression of retinopathy were then examined.

RESULTS

Of the 107 eyes of the 85 consecutive cases, 55 were without retinopathy (NR), 21 had background retinopathy (BDR), six had background retinopathy with macular oedema (BDR/MO), four had proliferative retinopathy and 12 cases had inadequate fundal view. In the NR and BDR groups, 90 and 81% of patients, respectively, had improved VA compared with 33% of patients with BDR/MO. Retinopathy progressed in 50% of BDR/MO patients compared with progression in 9 and 19% of NR and BDR patients, respectively.

CONCLUSION

The present study illustrates the poor visual outcome in patients with severe, untreated retinopathy, particularly maculopathy, following cataract surgery. Larger prospective studies are needed to better define risk groups and pre-operative treatment strategies.

Systemic diclofenac sodium to maintain mydriasis during phacoemulsification

PURPOSE

To determine whether systemic diclofenac sodium affects the maintenance of mydriasis during phacoemulsification and to compare pupil diameter regression rates with those in a control group.

SETTING

An ophthalmic unit of a National Health Service Trust Hospital in the United Kingdom.

METHOD

A prospective, randomized control study of 100 patients presenting for cataract surgery was undertaken. Both groups were administered an identical mydriatic regime commencing 1 hour before surgery. In addition, the diclofenac group (n = 48) received 50 mg of oral diclofenac sodium 1 hour before surgery. Both the control (n = 52) and diclofenac groups had phacoemulsification by one experienced surgeon using a standard technique. The surgeon was masked as to which group the patient belonged. The irrigating fluid in all cases contained adrenaline. Pupil diameter was measured at five stages during surgery and recorded along with the times relative to the start of the procedure.

RESULTS

Mean pupil diameter in the diclofenac group was slightly larger than in the control group, but the difference was not significant. Although mean pupil diameter at the start of surgery was 0.4 mm greater in the diclofenac group, the slopes of regression in pupil diameters were virtually identical between the first three stages of surgery, after which a slight reversal occurred in both groups. The slope of regression of mydriasis was small in both groups.

CONCLUSION

Systemic diclofenac sodium 50 mg given orally 1 hour before surgery did not significantly inhibit miosis when compared with a control group. Regression rates of pupil mydriasis were small in both groups.