Emerging guidelines for use of NSAID therapy to optimize cataract surgery patient care

Recent Insights into the Etiopathogenesis of Diabetic Retinopathy and Its Management

Purpose: Diabetic retinopathy (DR) is a microvascular retinal disease associated with chronic diabetes mellitus, characterized by the damage of blood vessels in the eye. It is projected to become the leading cause of blindness, given the increasing burden of the diabetic population worldwide. The diagnosis and management of DR pose significant challenges for physicians because of the involvement of multiple biochemical pathways and the complexity of ocular tissues. This review aims to provide a comprehensive understanding of the molecular pathways implicated in the pathogenesis of DR, including the polyo pathway, hexosamine pathway, protein kinase C (PKC), JAK/STAT signaling pathways, and the renin-angiotensin system (RAS). Methods: Academic databases such as PubMed, Scopus, Google Scholar and Web of Science was systematically searched using a carefully constructed search strategy incorporating keywords like "Diabetic Retinopathy," "Molecular Pathways," "Pharmacological Treatments," and "Clinical Trials" to identify relevant literature for the comprehensive review. Results: In addition to activating other inflammatory cascades, these pathways contribute to the generation of oxidative stress within the retina. Furthermore, it aims to explore the existing pharmacotherapy options available for the treatment of DR. In addition to conventional pharmacological therapies such as corticosteroids, antivascular endothelial growth factors, and nonsteroidal anti-inflammatory drugs (NSAIDs), this review highlights the potential of repurposed drugs, phyto-pharmaceuticals, and novel pipeline drugs currently undergoing various stages of clinical trials. Conclusion: Overall, this review serves as a technical exploration of the complex nature of DR, highlighting both established and emerging molecular pathways implicated in its pathogenesis. Furthermore, it delves into the available pharmacological treatments, as well as the promising repurposed drugs, phyto-pharmaceuticals, and novel drugs currently being evaluated in clinical trials, with a focus on their specific mechanisms of action.

Correlation between Severity of Idiopathic Epiretinal Membrane and Irvine-Gass Syndrome

A higher risk of pseudophakic cystoid macular edema (PCME) has been reported in patients with preoperative idiopathic epiretinal membrane (ERM); however, whether the formation of PCME depends on the grade of ERM has not been well established. We conducted a retrospective case-control study of 87 eyes of 78 patients who were preoperatively diagnosed with idiopathic ERM and had undergone cataract surgery. Patients were divided into two groups: PCME and non-PCME groups. After cataract surgery, the ERM status was graded using the Gass and Govetto classifications. Both the central macular thickness (CMT) and ERM grade increased after surgery, and higher preoperative CMT and ERM grades were found in the PCME group. The association between higher-grade ERM and the development of PCME was significant in the Govetto classification (grade 2, odds ratio (OR): 3.13; grade 3, OR: 3.93; and grade 4, OR: 16.07). The study results indicate that close attention should be given to patients with ERM with the presence of an ectopic inner foveal layer before cataract surgery.

Topical Treatment for Retinal Degenerative Pathologies: A Systematic Review

The topical administration of medicines is the preferred route in ocular therapy, at least for the anterior segment of the eye. However, the eye's inherent functional and biological barriers all work against the active pharmaceutical ingredient (API) to efficiently reach the targeted retinal structures. The main objective of this article is to offer a systematic review of the scientific literature in recent years, focusing on the latest developments of topical treatment intended for retinal degenerative diseases. Database search returned 102 clinical studies, focused on topical treatment for age macular degeneration, macular edemas (in diabetic retinopathy, surgery related or in retinal dystrophies) or glaucoma. After the exclusion of low-powered studies and those combining vitreo-retinal surgery, 35 articles remained for analysis. Currently, the topical treatment of retinal degenerative diseases is limited by the difficulty to deliver effective drug concentrations to the posterior eye structures. However, in the case of drug classes like NSAIDs, the presence of certain molecular and metabolic features for specific representatives makes the topical administration currently feasible in several clinical contexts. For other drug classes, either a fine-tuning of the API's pharmacokinetic profile or the use of more advanced formulation strategies, such as rationally designed nanostructured drugs and vehicles, crystalline polymorphs or supramolecular complexes, could bring the much awaited breakthrough for a more predictable and controlled delivery towards the retinal structures and could eventually be employed in the future for the development of more effective ways of delivering drugs to the posterior eye, with the ultimate goal of improving their clinical efficacy.

Clinical efficacy of Fluorometholone versus Loteprednol eye drops after photorefractive keratectomy: A triple-blinded randomized controlled trial

PURPOSE

This study aimed to compare the anti-inflammatory efficacy and safety of 0.1% Fluorometholone (FML) versus (vs.) 0.5% Loteprednol etabonate (LE) following photorefractive keratectomy (PRK).

METHODS

A triple-blinded randomized controlled trial was conducted on both eyes of 100 patients with stable refraction who were candidates for PRK. Both eyes in each subject were randomly allocated to the FML or LE groups. The product to be tested was 0.1% FML eye drops packaged in droppers vs. the 0.5% LE sterile ophthalmic suspension (Lotemax®) packaged in identical droppers. The main clinical outcomes were changes in best-corrected distance visual acuity (BCDVA) and corneal optical density. The second clinical outcomes were a change in intraocular pressure (IOP) after the intervention.

RESULTS

There was no significant difference regarding mean corneal optical density changes between the two groups, one (P = 0.55) and three months (P = 0.98) after the intervention. The mean ± SD BCDVA after one month of the intervention was 0.79 ± 0.11 and 0.84 ± 0.11 in LE and FML groups, retrospectively (P = 0.02). There was no significant difference regarding mean BCDVA between the two groups three months after intervention (P = 0.21). The IOP showed no significant difference between the two groups after one (P = 0.18) and three months (P = 0.53) of the intervention.

CONCLUSIONS

The results of this clinical trial demonstrate that LE and FML treatment was effective with no clinically meaningful effect on IOP following a short course of treatment.

Comparison of a preservative-free nonsteroidal anti-inflammatory drug and preservative-free corticosteroid after uneventful cataract surgery: multicenter, randomized, evaluator-blinded clinical trial

PURPOSE

To compare the efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs) and steroidal eyedrops for inflammation management after cataract surgery using slitlamp indicators.

SETTING

11 eye centers in South Korea.

DESIGN

Randomized prospective multicenter study with a blinded evaluator.

METHOD

In 125 (250 eyes) patients who underwent cataract surgery, bromfenac sodium hydrate 0.1% (NSAID group) was applied twice a day in 1 eye, whereas the other eye was treated with fluorometholone 0.1% (steroid group), 4 times a day for 4 weeks postoperatively. The primary efficacy outcome was the presence of anterior chamber cells and flare at 1 week postoperatively. Anterior chamber cells and flare at 4 to 8 weeks, corrected distance visual acuity, central corneal thickness, conjunctival hyperemia, dry eye parameters, foveal thickness, and ocular and visual discomfort were evaluated as secondary outcomes.

RESULTS

At week 1, residual anterior chamber inflammation was not statistically significantly different between the groups (-1.03 ± 1.27 vs -0.95 ± 1.24, P = .4850). However, the NSAID group recovered from conjunctival hyperemia more rapidly than the steroid group (0.30 ± 0.52 vs 0.44 ± 0.81, P = .0144 at week 1). The increase in central corneal thickness in the NSAID group was less than that in the steroid group 1 week postoperatively (7.87 ± 22.46 vs 29.47 ± 46.60 μm, P < .0001). The change in foveal thickness in the NSAID group was significantly less than that in the steroid group (18.11 ± 68.19 vs 22.25 ± 42.37 μm, P = .0002). Lower levels of postoperative ocular and visual discomfort were reported in the NSAID group than in the steroid group under treatment.

CONCLUSIONS

Preservative-free bromfenac was as effective as preservative-free fluorometholone eyedrops in anterior chamber inflammation control and showed better signs and symptoms after cataract 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.

Comparison of the efficacy of nepafenac 0.1% in quiescent Behçet's uveitis and non-uveitic healthy patients after phacoemulsification surgery

PURPOSE

To compare the efficacy of nepafenac on anterior chamber flare and intraocular pressure(IOP) in healthy (group 1) and uveitic eyes (group 2) undergoing cataract surgery.

METHODS

A retrospective, consecutive case series study.

RESULTS

Among 54 the patients, 14 had a history of uveitis. The groups were similar in age and gender. There were significant changes in flare values in both groups. When the temporal changes of flare values were compared, there was no difference between the two groups. There were no significant changes in IOP values in both group. When the temporal changes of IOP values were compared, there was no difference between the groups.

CONCLUSIONS

Nepafenac 0.1% has been shown to be effective in suppressing inflammation after cataract surgery in uveitic eyes as well as in healthy eyes. In addition, it has been observed that it does not increase intraocular pressure in both healthy and uveitic eyes and it is safe to use with this regard.

[Effectiveness of a nonsteroidal anti-inflammatory drug in the treatment of chronic non-infectious blepharitis]

Anti-inflammatory therapy is a type of etiopathogenetic treatment of chronic mixed blepharitis. Nonsteroidal anti-inflammatory drugs (NSAIDs) have pronounced anti-inflammatory effect comparable to the action of corticosteroids.

PURPOSE

To assess of the effectiveness of a NSAID - 0.09% bromfenac - in the treatment of chronic blepharitis of non-infectious etiology.

MATERIAL AND METHODS

The study included 37 patients (74 eyes), 31 women (62 eyes) and 6 men (12 eyes) with chronic blepharitis. All patients underwent clinical, functional, instrumental and laboratory examination. The treatment of patients of the main group consisted of instillations of 0.09% bromfenac ('Broxinac', Sentiss, India) once per day and artificial tears with lipid component 3 times a day for 30 days. Patients in the control group only used artificial tears with lipid component 3 times a day for 30 days. The follow-up included examinations at one week, one and two months.

RESULTS

The positive clinical and functional response after treatment corresponded to optimization of the state of microvasculature in both groups, however, the dynamics of changes in the control group were less pronounced.

CONCLUSION

Elimination of microcirculatory disorders in the eyelids and signs of inflammation of the ocular surface determine the etiopathogenetic direction of using 0.09% bromfenac in the conservative treatment of chronic mixed blepharitis.

Bromfenac Ophthalmic Solution 0.07% Versus Nepafenac Ophthalmic Suspension 0.3% for Post-Cataract Surgery Inflammation: A Pilot Study of Identical Dosing Regimens with Pre-Surgical "Pulse" Dose

Introduction

This small pilot study is the first direct comparison of the currently marketed formulations of bromfenac (0.07% solution) and nepafenac (0.3% suspension) using identical dosing regimens and including an extra pre-surgical “pulse” dose in patients undergoing cataract surgery.

Methods

Adults scheduled for unilateral phacoemulsification with intraocular lens implantation were randomly assigned to bromfenac 0.07% or nepafenac 0.3%, each given once-daily 1 day prior to surgery, on the day of surgery plus an extra dose 1 h before surgery, and for 14 days after surgery. Assessments included summed ocular inflammation score (SOIS), visual acuity (VA), and retinal thickness measured via optical coherence tomography.

Results

The study population included 49 patients (bromfenac, n = 24; nepafenac, n = 25). The percentage of patients with a SOIS = 0 (no cells or flare) at post-surgical day 15 (primary efficacy endpoint) was statistically similar between the bromfenac (57.1%) and nepafenac (50.0%) treatment groups (intent-to-treat with last observation carried forward) (P = 0.6318). The proportions of patients with an SOIS of 0 at days 3 and 8 were significantly (P < 0.05) higher in the bromfenac group (23.8 and 52.4%, respectively) versus the nepafenac group (0.0 and 20.8%, respectively). Visual acuity was similar between groups at each study visit, as were mean retinal thickness and change from baseline in retinal thickness. Rescue medication (typically difluprednate) was given on or before day 15 to 13 patients in each treatment group (bromfenac, 54.2%; nepafenac, 52.0%). There were no adverse events considered to be related to either treatment.

Conclusions

The results of this small pilot study suggest that once-daily bromfenac 0.07% produces similar benefits with regard to postsurgical inflammation, VA, and retinal thickness as once-daily nepafenac 0.3%, and possibly has a faster onset of anti-inflammatory action, when compared using identical dosing regimens.

Funding

Bausch & Lomb Incorporated.

Trial Registration

NCT03886779.

The effect of tea tree oil on dry eye treatment after phacoemulsification cataract surgery: A randomized clinical trial

PURPOSE

To evaluate the effect of eyelid scrubbing with eye shampoo containing tea tree oil on dry eye disease following phacoemulsification cataract surgery.

METHODS

This prospective triple-blinded randomized clinical trial was performed on 62 eyes of 62 patients. Patients were randomly assigned to two groups-(1) treatment group: for 33 patients in the treatment group, artificial tears, topical steroid drops, and eye shampoos with tea tree oil and (2) for 29 patients in the control group, artificial tears, topical steroids, and eye shampoos without tea tree oil were used. In the first and second (after 1 month) follow-up visits, microscopic Demodex examination, refraction, corrected distance visual acuity, the ocular surface disease index score (by the questionnaire), Schirmer test, tear break-up time test, and osmolarity of tears (by TearLab) were recorded in treatment and control groups.

RESULTS

The mean age of patients was 66.37 ± 8.83 (range: 37-82) years, of which 49 (79%) were female and 13 (21%) were male. The results showed a significant improvement in tear break-up time test, corrected distance visual acuity, osmolarity, and ocular surface disease index score in both groups (p < 0.05). However, the number of Demodex decreases significantly only in the treatment group after treatment (p <0.001). Tear break-up time, osmolarity, and ocular surface disease index scores in the treatment group were significantly better than the control group (p < 0.05). However, there was no significant difference between the two groups in the pre- and post-Schirmer test results (p > 0.05).

CONCLUSION

Eyelid scrubbing with eye shampoo containing tea tree oil is recommended for dry eye treatment after cataract surgery, especially decrease in the number of Demodex.

[Treatment of postoperative macular edema (a clinical case study)]

Pseudophakic cystoid macular edema (CMO) known to appear in 0.1-2.35% of patients after phacoemulsification is one of the common causes of vision decrease during the postoperative period. The authors analyze a case of CMO development in a pseudophakic patient diagnosed 7 months after uncomplicated phacoemulsification. Optical coherence tomography (OCT) was suggested for patients with low vision and a sensation of shroud before the eye for early diagnosis of pathological process. Intravitreal injection of the 0.7 mg dexamethasone micro-implant performed soon after establishing diagnosis was proved to be viable for postoperative CMO arrest in patients without previous treatment. One month after intravitreal implant injection the visual acuity in the patient's eye improved from 0.4 to 0.7, and retinal thickness in the macular area decreased from 705 to 255 μm. The result remained stable for 10 months. Intravitreal micro-implant appeared to have higher efficiency in contrast with traditional treatment methods (according to literature data), which was attributed to direct drug delivery to the area of pathological process. The use of 0.7 mg dexamethasone implant did not increase the intraocular pressure indicating its potential viability for patients with compensated glaucoma.

Cataract surgery and nonsteroidal antiinflammatory drugs

Nonsteroidal antiinflammatory drugs (NSAIDs) have become an important adjunctive tool for surgeons performing routine and complicated cataract surgery. These medications have been found to reduce pain, prevent intraoperative miosis, modulate postoperative inflammation, and reduce the incidence of cystoid macular edema (CME). Whether used alone, synergistically with steroids, or for specific high-risk eyes prone to the development of CME, the effectiveness of these medications is compelling. This review describes the potential preoperative, intraoperative, and postoperative uses of NSAIDs, including the potency, indications and treatment paradigms and adverse effects and contraindications. A thorough understanding of these issues will help surgeons maximize the therapeutic benefits of these agents and improve surgical outcomes.

FINANCIAL DISCLOSURE

Proprietary or commercial disclosures are listed after the references.

[Treatment of postoperative macular edema (a clinical case study)]

Pseudophakic cystoid macular edema (CMO) known to appear in 0.1-2.35% of patients after phacoemulsification is one of the common causes of vision decrease during postoperative period. The authors analyzed a case of CMO development in a pseudophakic patient diagnosed 7 months after uncomplicated phacoemulsification. Optical coherence tomography (OCT) was suggested for patients with low vision and a sensation of shroud before the eye for early diagnosis of pathological process. Intravitreal injection of the 0.7 mg dexamethasone micro-implant performed soon after establishing the diagnosis was proved to be viable for postoperative CMO arrest in patients without previous treatment. One month after intravitreal implant injection, the visual acuity in the patient's eye improved from 0.4 to 0.7, and retinal thickness in the macular area decreased from 705 to 255 μm. The result remained stable for 10 months. Intravitreal micro-implant appeared to have higher efficiency in contrast with traditional treatment methods (according to literature data), which was attributed to direct drug delivery to the area of pathological process. The use of 0.7 mg dexamethasone implant did not increase the intraocular pressure indicating its potential viability for patients with compensated glaucoma.

Electroacupuncture Attenuates Induction of Inflammatory Pain by Regulating Opioid and Adenosine Pathways in Mice

Although inflammatory pain is a common clinical condition, its mechanisms are still unclear. Electroacupuncture (EA), a well-known method of pain management, may reduce inflammatory pain by regulating neurons, astrocytes, and inflammatory signaling pathways. Injections of complete Freund’s adjuvant (CFA), which can initiate cell-mediated inflammatory pain, resulted in significant hyperalgesia, which was subsequently prevented by EA. In CFA-injected mice, a dramatic increase was observed in the expression of the following proteins in the dorsal root ganglion and spinal cord dorsal horn: the astrocytic marker GFAP, S100B, RAGE, pPKCε, COX-2, pERK, and pNFκB. These effects were reversed by EA. In addition, mechanical hyperalgesia was significantly reduced in the N6-cyclopentyladenosine (CPA) i.p. or i.m. and endomorphin (EM) i.p. groups. Neither EM i.m. nor EM i.p. exhibited any analgesic effect on thermal hyperalgesia. However, both CPA i.m. and CPA i.p. attenuated thermal hyperalgesia in the mouse inflammatory pain model. We showed that CPA reduced COX-2 and pPKCε expression. However, EM administration did not reduce COX-2 levels. Combined administration of naloxone and rolofylline increased pPKCε and COX-2 pathways. Taken together, our study results revealed a novel and detailed mechanism of EA-induced analgesia that involves the regulation of the opioid and adenosine pathways.

Intracameral ketorolac concentration at the beginning and end of cataract surgery following preoperative topical ketorolac administration

Purpose

To evaluate the intracameral concentration of ketorolac tromethamine (ketorolac) at the beginning and end of cataract surgery following preoperative topical administration.

Setting

Santa Barbara Surgery Center, Santa Barbara, CA, USA.

Design

This was a pre–post, interventional, single-arm study.

Patients and methods

Patients undergoing cataract extraction and lens replacement (CELR) were eligible. Written informed consent was obtained from 14 patients who were prescribed topical ophthalmic ketorolac according to the surgeon’s usual practice beginning the day prior to surgery. The surgeon withdrew 100 μL of aqueous humor from the operative eye immediately prior to the initial surgical incision and again just prior to final anterior chamber reinflation and wound closure. Ketorolac concentrations in the intracameral fluid samples were measured.

Results

Thirteen of 14 patients used four doses of ketorolac the day prior to surgery as directed, and one patient used three doses. On the day of surgery, all 14 patients administered one drop of topical ketorolac on awakening and one drop after arriving at the surgery center. Preoperative ketorolac concentrations for the 12 patients from whom samples were collected ranged from 4.9 to 369 ng/mL. End-of-procedure sample concentrations ranged from <1.0 (the lower limit of quantification [LLOQ]) to 6.32 ng/mL, with eight of 12 patients having ketorolac levels below the LLOQ.

Conclusion

At-home compliance with topical ketorolac was good, with 92.9% of patients using it as directed. Following CELR, levels of ketorolac in the aqueous humor were low, and 66.7% of patients had undetectable levels.

The Effect of Latanaprost on Intraocular Inflammation and Macular Edema

There is debate concerning whether the use of Latanoprost in early postoperative period of cataract surgery and in glaucoma patients with uveitis as it may aggravate the inflammation and results in macular edema (ME), because of blood-ocular barrier disruption. However, there is no solid evidence for disruption of blood-ocular barrier with Latanoprost and aggravation of uveitis or ME formation. Similar to pseudophakic ME, the imaging ME in cases claimed to be secondary to Latanoprost is greater than clinical ME, happens mostly in complicated surgeries, and the vast majority resolve within weeks to months with using a non-steroidal anti-inflammatory drug. The current literature suggests that Latanoprost can be used in patients with uveitis and early after cataract surgery with or without concomitant topical non-steroidal anti-inflammatory drugs that are currently used by many ophthalmologists as a preventive measure for ME even in non-glaucoma uncomplicated cataract surgeries.

Additive Effect of Oral Steroid with Topical Nonsteroidal Anti-inflammatory Drug for Preventing Cystoid Macular Edema after Cataract Surgery in Patients with Epiretinal Membrane

Purpose

To investigate the additive effect of oral steroid with topical nonsteroidal anti-inflammatory drug (NSAID) on cystoid macular edema (CME) in patients with epiretinal membrane (ERM) after cataract surgery.

Methods

Medical records of subjects who underwent uneventful cataract surgery (n = 1,349) were retrospectively reviewed; among these patients, those with pre-existing ERM (n = 81) were included. Patients were divided into two groups: one group had postoperative administration of oral steroid for 1 week (n = 45) and the other group did not have oral steroid administration (n = 36). Changes in macular thickness and incidence of CME were compared in both groups. Topical NSAIDs were administered in both groups for 1 month postoperatively. Definite CME and probable CME were defined by changes in retinal contour with or without cystoid changes. Change in central macular thickness of more than three standard deviations (≥90.17 µm) was defined as possible CME. Macular thickness was measured at 1 month after the operation by optical coherence tomography.

Results

The incidence of definite, probable, and possible CME were 2.22%, 4.44%, and 8.89% with the use of steroid and 2.78%, 5.56%, and 8.33% without steroid, respectively (p = 0.694, p = 0.603, and p = 0.625), and regardless of treatment group, the incidences in these patients were higher compared to incidences in whole subjects (1.26%, 2.30%, and 4.32%; p = 0.048, p = 0.032, and p = 0.038, respectively). The differences in macular thickness were not statistically different between the two groups. Average changes of central foveal thickness in 3 mm and 6 mm zone were 29.29 µm, 35.93 µm, and 38.02 µm with the use of steroid and 32.25 µm, 44.08 µm, and 45.39 µm without steroid (p = 0.747, p = 0.148, and p = 0.077, respectively).

Conclusions

This study suggests that administration of oral steroid may not have a synergistic effect in reduction of CME and retinal thickness in patients with pre-existing ERM after cataract surgery, when topical NSAIDs are applied.

Comparison of the efficacy and patients' tolerability of Nepafenac and Ketorolac in the treatment of ocular inflammation following cataract surgery: A meta-analysis of randomized controlled trials

As a new ophthalmic non-steroidal anti-inflammatory drug (NSAID) with prodrug structure, Nepafenac was supposed to have a better efficacy than conventional NSAIDs both in patients’ tolerability and ocular inflammation associated with cataract surgery. However, many current studies reached contradictory conclusions on the superiority of Nepafenac over Ketorolac. The objective of our study is to evaluate the efficacy and patients’ tolerability of Nepafenac and Ketorolac following cataract surgery. To clarify this, we conducted a meta-analysis of randomized controlled trials. Eleven articles were included in this study. The dataset consisted of 1165 patients, including 1175 cataract surgeries. Among them, 574 patients were in the Nepafenac group and 591 in the Ketorolac group. Our analysis indicated that these two drugs were equally effective in controlling post cataract surgery ocular inflammation, reducing macular edema, achieving a better visual ability and maintaining intraoperative mydriasis during cataract surgery. However, Nepafenac was more effective than Ketorolac in reducing the incidence of postoperative conjunctival hyperemia and ocular discomfort. This meta-analysis indicated that topical Nepafenac is superior to Ketorolac in patients’ tolerability following cataract surgery. However, these two drugs are equally desirable in the management of anterior chamber inflammation, visual rehabilitation and intraoperative mydriasis. Given the limitations in our study, more researches with larger sample sizes and focused on more specific indicators such as peak aqueous concentrations of drugs or PEG2 levels are required to reach a firmer conclusion.

Nanostructured lipid carrier (NLC)-based novel hydrogels as potential carriers for nepafenac applied after cataract surgery for the treatment of inflammation: design, characterization and in vitro cellular inhibition and uptake studies

Schematic illustration of the novel formulation (nanostructured lipid carriers-based novel hydrogels) instills into the surface of eyes and the results of cytotoxicity and cell uptake for optimal formulation.

Comparison of Preoperative Topical Dexamethasone Phosphate Versus Ketorolac Tromethamine in Maintaining Intraoperative Mydriasis During Small Incision Cataract Surgery

INTRODUCTION

Intraoperative miosis is one of the many challenges which a surgeon can face during cataract surgery. It may lead to impaired view and difficulty in delivering the nucleus. Also, it increases the chances of more serious intraoperative and postoperative complications. Therefore, maintaining adequate pupillary dilatation is of utmost importance during cataract surgery.

AIM

To study the efficacy of topical dexamethasone phosphate (0.1%) and topical ketorolac tromethamine (0.4%) in maintaining pupillary dilatation during cataract surgery.

MATERIALS AND METHODS

A total of 200 patients were studied. These were randomly divided into two groups of 100 each. Group1 was given topical dexamethasone phosphate (0.1%) and Group 2, topical ketorolac tromethamine (0.4%). Medications were started 1-day before surgery in the form of one drop to be instilled every 6 hours. Pupillary diameter was measured in the horizontal meridian; 4 readings were taken - before making the incision, after nucleus delivery, following cortical clean-up and after Intraocular Lens (IOL) implantation.

RESULTS

The two drugs showed no statistically significant difference in pupillary diameter at the commencement of surgery (p=0.435). The difference between the two drugs was statistically significant, for the mean pupillary diameter which changed from the start of surgery to after cortical clean-up. At this stage, ketorolac group showed a tendency towards larger mean pupillary diameter than dexamethasone group (6.70 ± 0.85mm and 6.32 ± 0.84mm, respectively, p=0.002). Again, ketorolac group patients had larger pupillary diameter after IOL implantation than dexamethasone group patients (the mean was 6.16± 0.97mm and 5.75 ± 0.73mm, respectively, p=0.001).

CONCLUSION

Both ketorolac tromethamine (0.4%) and dexamethasone phosphate (0.1%) are effective in maintaining adequate mydriasis during cataract surgery, but the comparative analysis of the two drugs concludes that, ketorolac is definitely a better option in preventing surgically induced miosis.

The effect of topical sodium diclofenac on macular thickness in diabetic eyes after phacoemulsification: a randomized controlled trial

To evaluate the efficacy of prophylactic administration of the topical diclofenac 0.1 % on macular thickness in diabetic patients following phacoemulsification and intraocular lens implantation surgery. In a Randomized double-masked clinical trial, 108 eyes of 108 diabetic patients underwent phacoemulsification and intraocular lens implantation surgery were enrolled. Fifty four eyes received the conventional postoperative care with steroid drop, whereas the other group (54 eyes) was given a preoperative diclofenac drop four times daily in addition to steroid drop and continued 6 weeks after surgery. All patients were evaluated by optical coherence tomography (OCT) preoperatively and days 1, 30, and 90. The outcome measures including best-corrected visual acuity and OCT findings were compared in and between both groups. Mean CMT changed from 239 ± 16 and 235 ± 17 at baseline to 249 ± 15 and 254 ± 28 at 3 months in the case and control groups, respectively(p = 0.003). Mean total volume of macula changed from 7.61 ± 0.22 and 7.56 ± 0.3 at baseline to 7.64 ± 0.22 and 7.65 ± 0.31 at 3 months in the case and control groups, respectively (p = 0.820). In comparison to the quadrants thicknesses and mean of them between groups did not reach the significant level. This study showed that there is a beneficial effect of topical diclofenac for prevention of macular thickness increasing following phacoemulsification in diabetic patients.

One-Day Use of Preoperative Topical Nonsteroidal Anti-Inflammatory Drug Prevents Intraoperative Prostaglandin Level Elevation During Femtosecond Laser-Assisted Cataract Surgery

PURPOSE

To determine if pretreatment with topical nonsteroidal anti-inflammatory drug (NSAID) prior to femtosecond laser-assisted cataract surgery (FLACS) prevents intraoperative prostaglandin level elevation as a potential risk factor of postoperative complications.

PATIENTS AND METHODS

Thirty-six patients with clinically significant cataract and without any concomitant general or ophthalmic disease were enrolled into the three age-matched groups of the study. The mean age of the patients was 62.3 ± 13.1 years. The first group of patients underwent traditional phacoemulsification (Control group), on the second group of patients FLACS was performed, and the third group of patients received topical 0.1% nepafenac pretreatment for 1one day prior to FLACS. Before the phacoemulsification part of the cataract surgery, approximately 110 µL of aqueous humor was collected in all groups. Total prostaglandin concentrations of the collected aqueous humor samples were evaluated by enzyme immunoassay (EIA).

RESULTS

The mean of the total prostaglandin concentrations of the aqueous humor samples was 208.8 ± 140.5 pg/mL in patients in the control group, 1449.1 ± 1019.7 pg/mL in the FLACS group (p > 0.001), and 92.2 ± 51.7 pg/mL in the group pretreated with topical NSAID before the FLACS (p > 0.001 compared to FLACS; p > 0.01 compared to control), respectively.

CONCLUSIONS

FLACS surgery increases intracameral prostaglandin concentration. However, using preoperative 1-day-long nonsteroid anti-inflammatory drops prior to FLACS, this intraoperative increase diminishes. Our study raises the possibility that NSAID pretreatment may be routinely administered before FLACS cataract surgeries to achieve a further decrease in the potential complications of increased total prostaglandin concentration during FLACS surgeries.

Design and elaboration of freeze-dried PLGA nanoparticles for the transcorneal permeation of carprofen: Ocular anti-inflammatory applications

This work aimed the design and development of poly(lactic-co-glycolic) acid (PLGA) nanoparticles (NPs) for the ocular delivery of Carprofen (CP) by a central rotatable composite design 2(3)+ star. NPs showed adequate size for ocular administration (189.50 ± 1.67 nm), low polydispersity (0.01 ± 0.01), negative charge surface (-22.80 ± 0.66 mV) and optimal entrapment efficiency (74.70 ± 0.95%). Physicochemical analysis confirmed that CP was dispersed inside the NPs. The drug release followed a first order kinetic model providing greater sustained CP release after lyophilization. Ex vivo permeation analysis through isolated rabbit cornea revealed that a sufficient amount of CP was retained in the tissue avoiding excessive permeation and thus, potential systemic levels. Ex vivo ocular tolerance results showed no signs of ocular irritancy, which was also confirmed by in vivo Draize test. In vivo ocular anti-inflammatory efficacy test confirmed an optimal efficacy of NPs and its potential application in eye surgery.

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

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

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 nepafenac 0.1% for treatment of chronic uveitic cystoid macular edema

PURPOSE

To describe the efficacy of nepafenac ophthalmic suspension 0.1% (Nevanac; Alcon Laboratories, Inc.) for treating cystoid macular edema (CME) resulting from uveitis.

DESIGN

Interventional case series

METHODS

: Three patients with a history of decreased visual acuity due to uveitic CME despite previous treatment with topical steroids or traditional nonsteroidal antiinflammatory drugs, intravitreal triamcinolone acetonide (Kenalog; Bristol-Myers Squibb), or immunosuppressive agents were given topical nepafenac 0.1%. Patients were monitored for clinical improvement, decreased retinal thickness by optical coherence tomography, and improved Snellen visual acuity.

RESULTS

For all three patients, treatment with topical nepafenac for 4 weeks to 3 months led to improvement in visual acuity and decrease in retinal thickness.

CONCLUSIONS

The improved visual acuity and decreased retinal thickness in these patients suggest that nepafenac is an effective treatment of inflammation and CME in the posterior segment of the eye for patients with chronic uveitis.

The ocular distribution of (14)C-labeled bromfenac ophthalmic solution 0.07% in a rabbit model

PURPOSE

To evaluate the ocular distribution of an advanced formulation of bromfenac ophthalmic solution. Two studies were conducted in rabbits: 1) a 12-hour parallel-group study comparing the ocular distribution of (14)C-bromfenac ophthalmic solution 0.07%, pH 7.8 with that of (14)C-bromfenac ophthalmic solution 0.09%, pH 8.3, and 2) a 24-hour study evaluating the ocular distribution of (14)C-bromfenac ophthalmic solution 0.07%, pH 7.8.

METHODS

In the 12-hour study, rabbits were randomized to receive 50 μL of (14)C-bromfenac 0.07%, pH 7.8 or 50 μL (14)C-bromfenac 0.09%, pH 8.3 in one eye, whereas, in the 24-hour, study both eyes received 50 μL of (14)C-bromfenac 0.07%, pH 7.8. Ocular tissues were collected at 1, 2, 4, 8, 12 (both studies) and 24 hours (second study only) following drug instillation, and tissue radioactivity was determined using liquid scintillation chromatography.

RESULTS

Measureable levels of bromfenac were observed in all ocular tissues, with the exception of vitreous humor, regardless of formulation. In the 12-hour study, high concentrations of (14)C-bromfenac were found in the sclera, followed by the iris/ciliary body, aqueous humor, choroid, retina, and lens. There was no significant difference between the bromfenac 0.07%, pH 7.8 and bromfenac 0.09%, pH 8.3 formulations in any (14)C-bromfenac tissue levels at any time point, with the exception of in sclera at 2 hours post-instillation (0.451 μg eq/g versus 0.302 μg eq/g, respectively, P<0.001). There was also no significant difference in the total amount of (14)C-bromfenac in the tissues evaluated following instillation of the two formulations. In the 24-hour study evaluating bromfenac 0.07%, pH 7.8 only, high concentrations of (14)C-bromfenac were found 1 hour post-instillation in the cornea (2.402 μg eq/g) and conjunctiva (1.049 μg eq/g), two tissues not evaluated in the 12-hour study. The rank order of (14)C-bromfenac levels in the other ocular tissues was the same as that observed in the 12-hour study, with measureable amounts of (14)C-bromfenac detected through 24 hours in all tissues with the exception of vitreous humor.

CONCLUSION

Bromfenac ophthalmic solution 0.07%, pH 7.8 readily penetrated ocular tissues with levels similar to those of bromfenac ophthalmic solution 0.09%, pH 8.3.

Management of pseudophakic cystoid macular edema

Pseudophakic cystoid macular edema (PCME) is a common complication following cataract surgery. Acute PCME may resolve spontaneously, but some patients will develop chronic macular edema that affects vision and is difficult to treat. This disease was described more than 50 years ago, and there are multiple options for clinical management. We discuss mechanisms, clinical efficacy, and adverse effects of these treatment modalities. Topical non-steroidal anti-inflammatory agents and corticosteroids are widely used and, when combined, may have a synergistic effect. Intravitreal corticosteroids and anti-vascular endothelial growth factor (anti-VEGF) agents have shown promise when topical medications either fail or have had limited effects. Randomized clinical studies evaluating anti-VEGF agents are needed to fully evaluate benefits and risks. When PCME is either refractory to medical therapy or is associated with significant vitreous involvement, pars plana vitrectomy has been shown to improve outcomes, though it is associated with additional risks.

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.

Evaluation of nepafenac in prevention of macular edema following cataract surgery in patients with diabetic retinopathy

Background

The purpose of this study was to evaluate nepafenac ophthalmic suspension 0.1% (Nevanac^®; Alcon Research Ltd) in the prevention of macular edema following cataract surgery in diabetic retinopathy patients.

Methods

This was a multicenter, randomized, double-masked, vehicle-controlled study of 263 adult diabetic patients with nonproliferative diabetic retinopathy requiring cataract surgery. Patients were randomized (1:1) to instill nepafenac or vehicle three times daily beginning 1 day prior to surgery through day 90. Efficacy included the percentage of patients who developed macular edema (≥30% increase in central subfield macular thickness from baseline) and the percentage of patients with decreases of more than five letters in best-corrected visual acuity from day 7 to 90.

Results

A significantly lower percentage of patients in the nepafenac group developed macular edema relative to patients in the vehicle group (3.2% versus 16.7%; P < 0.001). A significantly lower percentage of patients in the nepafenac group had best-corrected visual acuity decreases of more than five letters relative to patients in the vehicle group on day 30 (P < 0.001), day 60 (P = 0.002), and day 90 (P = 0.006). The mean central subfield macular thickness and mean percent change from baseline in macular volume were also significantly lower in the nepafenac group versus the vehicle group at days 14 through 90 (P ≤ 0.005). No safety issues or trends were identified when dosing was increased to 90 days that negatively impacted the favorable benefit/risk profile of nepafenac.

Conclusion

Nepafenac demonstrated statistically significant and clinically relevant advantages compared with vehicle in preventing macular edema and maintaining visual acuity in diabetic patients following cataract surgery. These advantages were seen at multiple time points over the course of the 90-day therapy period. There was no clinically relevant increase in risk from 90 days dosing compared with 14 days. Therefore, with a similar safety profile and benefit in preventing macular edema and maintaining vision, the risk/benefit to the diabetic patient undergoing cataract surgery appears to be positive.

Comparison of bromfenac 0.09% QD to nepafenac 0.1% TID after cataract surgery: pilot evaluation of visual acuity, macular volume, and retinal thickness at a single site

Purpose

The purpose of this study was to investigate the clinical outcomes of bromfenac ophthalmic solution 0.09% once daily (QD) and nepafenac 0.1% ophthalmic suspension three times daily following cataract extraction with posterior chamber intraocular lens implantation, specifically looking at any differences in Early Treatment Diabetic Retinopathy Study visual acuities, macular volume, and/or retinal thickness changes.

Methods

Subjects were randomly assigned to receive either bromfenac (n = 10) QD or nepafenac (n = 10) three times daily. Dosing began 3 days before cataract surgery, continuing to day 21 postsurgery. In addition to the investigated nonsteroidal antiinflammatory drug regimen, all subjects received antiinfective intraoperative and postoperative standard of care. Subjects were followed at 1 day and 1, 3, and 6 weeks postoperatively. Study visit assessments included best-corrected visual acuity, biomicroscopy, summed ocular inflammation score (anterior chamber cells and flare grading), intraocular pressure measurement, adverse event recording, and concomitant medication review. Optical coherence tomography was performed at 1, 3, and 6 weeks.

Results

Both treatment groups had similar baseline measurements. Outcomes for mean letters read (P = 0.318), mean change in macular volume (P = 0.665), and retinal thickness (P = 0.552) were not statistically different between the groups from baseline through week six, although independently only the bromfenac group demonstrated a statistically significant improvement in letters gained from baseline to week six (P = 0.040). In the same time period, mean macular volume and retinal thickening worsened in the nepafenac group, demonstrating a statistically significant increase (P = 0.006) at week six for macular volume when compared to baseline. One subject in the nepafenac group experienced recurrent inflammation at week six, was unmasked, and then rescued with bromfenac 0.09% QD and difluprednate 0.05% QD.

Conclusion

Both bromfenac and nepafenac resulted in positive clinical outcomes of Early Treatment Diabetic Retinopathy Study visual acuities. Postoperative measurements of macular volume and retinal thickness of bromfenac subjects showed a trend toward improved vision, less retinal thickening, and more stable macular volumes overall.

Refractory cystoid macular oedema due to intraocular lens haptic perforating the iris

Cystoid macular oedema is a well-known complication of cataract surgery associated with intraocular lens decentration or dislocation. A 55-year-old man, who had undergone a phacoemulsification and intraocular lens implantation surgery two months previously was referred because of reduced vision in the right eye. Ocular examination revealed that one of the haptics had perforated the iris at 6 o'clock. There was cystoid macular oedema of the right eye. A topical non-steroid anti-inflammatory drug, followed by intravitreal injections did not produce a significant regression. Finally, the haptic was repositioned surgically and the macular oedema dramatically resolved. Correct placement of the intraocular lens might avoid post-operative complications including cystoid macular oedema.

Ketorolac 0.45% ophthalmic solution

Ketorolac 0.45% ophthalmic solution is a topical NSAID indicated in the US for the treatment of ocular pain and inflammation following cataract surgery. In animal studies, the ocular relative bioavailability of single-dose topical ketorolac 0.45% ophthalmic solution was 2- to 3-fold higher than that of ketorolac 0.4% ophthalmic solution. In two identically designed, randomized, double-masked, multicentre trials in adult patients undergoing cataract extraction, the proportions of patients with a summed ocular inflammation score of zero for anterior chamber cell count plus anterior chamber flare on day 14 after surgery were significantly greater in those treated with topical ketorolac 0.45% ophthalmic solution than in those treated with vehicle placebo. Compared with placebo, topical ketorolac 0.45% ophthalmic solution significantly increased the proportion of patients who were pain-free on the day after surgery in both trials. Ketorolac 0.45% ophthalmic solution was generally well tolerated in clinical trials with lower overall incidences of treatment-emergent and treatment-related adverse events than placebo, and with no single treatment-related adverse event having a higher incidence than with placebo.

Safety and efficacy of bromfenac ophthalmic solution (Bromday) dosed once daily for postoperative ocular inflammation and pain

PURPOSE

To evaluate the efficacy and ocular safety of bromfenac ophthalmic solution (bromfenac) 0.09% dosed once daily for the treatment of ocular inflammation and pain after cataract surgery with posterior chamber intraocular lens implantation.

DESIGN

Randomized, double-masked, vehicle-controlled or active-controlled, multicenter, clinical trials.

PARTICIPANTS AND CONTROLS

A total of 872 subjects (872 study eyes: bromfenac in 584, placebo in 288).

METHODS

Four randomized, double-masked, vehicle or active-controlled, clinical trials were conducted at 134 ophthalmology clinics in the United States. Subjects aged ≥ 18 years were randomized to receive either bromfenac 0.09% or placebo dosed once daily beginning 1 day before cataract surgery (day -1), continuing on the day of surgery (day 0), and continuing for an additional postoperative 14 days. Subjects were evaluated for efficacy and safety on days 1, 3, 8, 15, and 22. The primary efficacy end point was cleared ocular inflammation, measured by the summed ocular inflammation score (SOIS; anterior chamber cells and flare) by day 15. The secondary efficacy end point was the number of subjects who were pain-free at day 1. The data from the 4 trials were pooled for analyses.

MAIN OUTCOME MEASURES

The SOIS and ocular pain.

RESULTS

The proportion of subjects who had cleared ocular inflammation by day 15 was significantly higher in the bromfenac 0.09% group than in the placebo group (P < 0.0001). The mean SOIS in the bromfenac 0.09% group was significantly lower than in the placebo group at days 3, 8, 15, and 22 (P < 0.0001). The proportion of subjects who were pain-free at days 1, 3, 8, and 15 was significantly higher in the bromfenac 0.09% group than in the placebo group (P < 0.0001). The incidence of adverse events reported in the bromfenac 0.09% group was significantly lower than in the placebo group (P < 0.0001). On day 15, 84.0% of the bromfenac subjects had ≥ 1-line improvement in visual acuity compared with 66.1% of placebo subjects (P < 0.0001).

CONCLUSIONS

Bromfenac 0.09% dosed once daily was clinically safe and effective for reducing and treating ocular inflammation and pain associated with cataract surgery.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

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%.

Ocular penetration and anti-inflammatory activity of ketorolac 0.45% and bromfenac 0.09% against lipopolysaccharide-induced inflammation

PURPOSE

Anti-inflammatory activity of topical nonsteroidal anti-inflammatory drugs is mediated by suppression of cyclooxygenase (COX) isoenzymes. This study compared ocular penetration and inflammation suppression of topical ketorolac 0.45% and bromfenac 0.09% ophthalmic solutions in a rabbit model.

METHODS

At hour 0, 36 rabbits received ketorolac 0.45%, bromfenac 0.09%, or an artificial tear 3 times once every 20 min. Half of the rabbits in each group then received intravenous injections of lipopolysaccharide (LPS) and fluorescein isothiocyanate (FITC)-dextran at hour 1, and the other half at hour 10. Aqueous and iris-ciliary body (ICB) samples were collected in the former group at hour 2 (peak) and in the latter group at hour 11 (trough) An additional group of 6 animals received only FITC-dextran, and samples were collected 1 h later. Peak and trough nonsteroidal anti-inflammatory drug concentrations were compared with previously determined half-maximal inhibitory concentrations (IC(50)) for COX isoenzymes.

RESULTS

Peak and trough aqueous and ICB concentrations of ketorolac were at least 7-fold or greater than those of bromfenac. At peak levels, both ketorolac 0.45% and bromfenac 0.09% significantly inhibited LPS-induced aqueous prostaglandin E(2) and FITC-dextran elevation (P < 0.01). At trough, both study drugs significantly inhibited LPS-induced aqueous prostaglandin E(2) elevation (P < 0.05), but only ketorolac 0.45% significantly reduced LPS-induced aqueous FITC-dextran elevation (P < 0.01). Aqueous and ICB ketorolac concentrations exceeded its IC(50) for COX-1 and COX-2 at peak and trough. Aqueous and ICB bromfenac levels exceeded its IC(50) for COX-2 at peak and trough, but not for COX-1 at trough aqueous levels and peak and trough ICB levels.

CONCLUSIONS

Both ketorolac 0.45% and bromfenac 0.09% effectively suppressed inflammation at peak. At trough, only ketorolac 0.45% effectively suppressed inflammation as measured by FITC-dextran leakage. The difference in inflammation suppression may be due to differences in tissue concentrations and/or greater COX-1 suppression by ketorolac 0.45%.