Effect of topical nepafenac in prevention of macular edema after cataract surgery in patients with non-proliferative diabetic retinopathy

Comparison of the efficacy of Diclofenac 0.1% and Nepafenac 0.1% on anterior chamber cells in patients undergoing cataract surgery: A prospective clinical practice trial

Objectives

To compare the efficacy of topical Nepafenac 0.1 % and Diclofenac 0.1% eye drops in reducing the aqueous cells in the anterior chamber in an un-eventful post cataract surgery.

Methods

This prospective, clinical trial was conducted at an Eye OPD of Qazi Hussain Ahmad Medical Complex, Nowshera from January till December 2021. Ophthalmic assessment included Visual acuity (VA), slit-lamp examination, Intraocular pressure (IOP), Central macular thickness (CMT) by Optical coherence tomography (OCT) and anterior chamber-aqueous cells measurement pre-operatively and at day 1st, 2nd, 4th and 8th week post-operatively. Patients were randomly allocated to topical diclofenac 0.1% (TD) four times a day and nepafenac 0.1% (TN) three times a day for four weeks each along with topical steroids and antibiotics.

Results

Seventy patients (70) were randomly distributed into two treatment arms of 35 each. In both the arms VA improved which achieved a level of statistical significance post-operatively, however statistically insignificant difference was observed between the groups at 8th week follow up visit (p= 0.62). However, IOP and CMT values didn't achieve statistical significance between the arms pre and post operatively. In TN arm, level of AC-cells at 2nd and 4th week post-operatively were significantly lower (10.54 ± 4.05 and 08.20 ± 4.44) than TD arm (11.28 ± 5.04 and 09. 66 ± 5.50) with statistically significant difference (p < 0.05).

Conclusions

Topical Nepafenac 0.1% was more effective in suppressing the anterior chamber inflammation as compared to diclofenac during the early few post-operative weeks.

Effect of Phacoemulsification on Sub Foveal Choroidal and Central Macular Thickness as measured by Swept Source Optical Coherence Tomography

Objectives

To study the effect of Phacoemulsification on Sub Foveal Choroidal Thickness (SFCT) and Central Macular Thickness (CMT) as measured by Swept Source Optical Coherence Tomography (OCT).

Methods

This experimental study was conducted at Armed Forces Institute of Ophthalmology (AFIO), Rawalpindi from April 2021 to February 2022. One hundred eyes of 100 patients with age related cataract underwent uneventful phacoemulsification surgery. Pre-operative SFCT and CMT was measured and compared with SFCT and CMT at one week, one month and three months after surgery using swept source OCT.

Results

Mean age of study population was 56.76±8.31 years. Out of 100 patients, 46 (46%) were males and 54 (54%) were females. Mean pre-operative CMT, one week, one month and three months post-operative CMT was 233.95±9.46 μm, 232.88±8.59 μm, 230.38±10.62 μm and 230.67±7.55 μm respectively. Mean pre-operative SFCT, one week, one month and three months post-operative SFCT was 337.14±8.41 μm, 339.14±9.63 μm, 339.39±11.96 μm and 351.39±9.19 μm respectively. The difference of mean change in CMT from baseline at one week, one month and three months post-operatively was not statistically significant. The difference of mean change in SFCT from baseline at one week and one month post-operatively was not statistically significant. However, the difference of mean change in SFCT from baseline at three months post-operatively was statistically significant (p<0.05).

Conclusion

Uneventful phacoemulsification surgery does not have any effect on central macular thickness, however there is a significant increase in subfoveal choroidal thickness at three months after surgery.

Prophylactic interventions for preventing macular edema after cataract surgery in patients with diabetes: A Bayesian network meta-analysis of randomized controlled trials

BACKGROUND

Diabetes significantly increases the risk of postoperative macular edema (PME) after cataract surgery, leading to potential worst post-operative outcomes. This study aims to compare the effect of different prophylactic interventions in improving postoperative anatomic and visual acuity outcomes of diabetes patients who underwent cataract surgery.

METHODS

We searched MEDLINE, Embase, Web of Science databases from inception until February 2nd, 2022, for studies including studies reporting PME events and/or best-corrected visual acuity (BCVA) outcomes. Random-effects Bayesian network meta-analysis was performed to compare the efficiency of intravitreal anti-vascular endothelial growth factor injections (anti-VEGF), nonsteroidal anti-inflammatory drugs (NSAIDs) and topical steroids eye drop at 1 week, 1 month, 3 months, 6 months after cataract surgery.

FINDINGS

The total of 2566 participants from 17 randomized controlled trials were included in the network meta-analysis, with moderate risk of bias and no evidence of publication of bias. Compared to placebo/steroid eye drop alone, patients received additional topical NSAIDs or intravitreal anti-VEGF injections had lower risk of PME at 1 month (NSAIDs: OR=0·221, 95% Confidence interval [CI], 0·044-0·755, I² =0·0%, 5 studies; anti-VEGF: OR=0·151, 95%CI, 0·037-0·413, I² =0·0%, 5 studies) and 3 month (NSAIDs: OR=0·370, 95%CI, 0·140-0·875, I² =0·0%, 8 studies; anti-VEGF: OR=0·203, 95%CI, 0·101-0·353, I² =0·0%, 4 studies) after cataract surgery. Further, additional anti-VEGF exhibited better BCVA outcome at 1 month (mean difference of LogMAR: -0·083, 95%CI, -0·17 to -0·014, I² =62·0%, 5 studies), and 3 months (mean difference of LogMAR: -0·061, 95%CI, -0·11 to -0·011, I² =0·0%, 5 studies) after cataract surgery. Such additional benefits did not reach statistic significant at 6 months after surgery.

INTERPRETATION

Our data suggests that compared to placebo/steroid eye drop alone, additional prophylactic anti-VEGF intervention could be considered for preventing the occurrence of PME after cataract surgery in patients with diabetes.

FUNDING

Research and Development of Special (2020-1-2052); Science & Technology Project of Beijing Municipal Science & Technology Commission (Z201100005520045, Z181100001818003).

Estimating the Severity of Visual Field Damage From Retinal Nerve Fiber Layer Thickness Measurements With Artificial Intelligence

Purpose

The purpose of this study was to assess the accuracy of artificial neural networks (ANN) in estimating the severity of mean deviation (MD) from peripapillary retinal nerve fiber layer (RNFL) thickness measurements derived from optical coherence tomography (OCT).

Methods

Models were trained using 1796 pairs of visual field and OCT measurements from 1796 eyes to estimate visual field MD from RNFL data. Multivariable linear regression, random forest regressor, support vector regressor, and 1D convolutional neural network (CNN) models with sectoral RNFL thickness measurements were examined. Three independent subsets consisting of 698, 256, and 691 pairs of visual field and OCT measurements were used to validate the models. Estimation errors were visualized to assess model performance subjectively. Mean absolute error (MAE), root mean square error (RMSE), median absolute error, Pearson correlation, and R-squared metrics were used to assess model performance objectively.

Results

The MAE and RMSE of the ANN model based on the testing dataset were 4.0 dB (95% confidence interval = 3.8–4.2) and 5.2 dB (95% confidence interval = 5.1–5.4), respectively. The ranges of MAE and RMSE of the ANN model on independent datasets were 3.3–5.9 dB and 4.4–8.4 dB, respectively.

Conclusions

The proposed ANN model estimated MD from RNFL measurements better than multivariable linear regression model, random forest, support vector regressor, and 1-D CNN models. The model was generalizable to independent data from different centers and varying races.

Translational Relevance

Successful development of ANN models may assist clinicians in assessing visual function in glaucoma based on objective OCT measures with less dependence on subjective visual field tests.

Nepafenac in cataract surgery

The role of topical non-steroidal anti-inflammatory drugs (NSAIDs) in routine cataract surgery has been established since decades. Topical NSAIDs have been shown to reduce postoperative ocular inflammation and pain, preserve intraoperative mydriasis, and reduce the risk of postoperative cystoid macular oedema, whilst carrying a very low side-effect profile. Nepafenac is one of the currently available topical NSAIDs. The studies have shown that is has a high ocular penetration, allowing for potentially better results than other NSAIDs. This review gathers the current literature on the role of nepafenac in cataract surgery aiming to help surgeons maximise the benefits of its use to achieve improved surgical outcomes.

Pharmacotherapeutic management of macular edema in diabetic subjects undergoing cataract surgery

INTRODUCTION

Cataracts and diabetes are widespread pathologies that are of growing concern to the global population. In diabetic patients who have had cataract surgery, the worsening of preexisting diabetic macular edema or occurrence of pseudophakic cystoid macular edema are common causes of visual impairment even with the most advanced surgical techniques available today for phacoemulsification.

AREAS COVERED

In this review, the authors assess the available literature to evaluate and compare different drugs, with the aim of establishing the best pharmacological strategies for the prevention and treatment of macular edema in diabetic patients undergoing cataract surgery.

EXPERT OPINION

Guidelines for the optimal management of diabetic macular edema in conjunction with cataract surgery or treatment of pseudophakic cystoid macular edema in diabetic patients are still lacking. To treat these conditions, clinicians need to understand the pharmacokinetics, posology, and efficacy of available drugs: topical non-steroidal anti-inflammatory drugs (NSAIDs), intravitreal anti-vascular endothelial growth factors (VEGFs), and both topical and intravitreal steroids. Diabetic patients undergoing cataract surgery should receive topical NSAIDs to prevent pseudophakic cystoid macular edema. Intravitreal anti-VEGFs and steroids, in association with cataract surgery, are indicated for patients with preexisting diabetic macular edema or those at high risk of macular edema after surgery.

Topical nepafenac for prevention of post-cataract surgery macular edema in diabetic patients: patient selection and perspectives

Since its first description, the prevention of pseudophakic cystoid macular edema (PCME) continues to pose challenges for ophthalmologists. Recent evidence suggests that prophylaxis is unnecessary in patients without risk factors. Diabetes mellitus is generally considered as a risk factor for the development of PCME after cataract surgery since it causes breakdown of the blood–retinal barrier. Diabetic retinopathy (DR) increases the risk even further. Therefore, prophylactic nonsteroidal anti-inflammatory drugs (NSAIDs) should be considered in diabetic patients, especially if they have DR. NSAIDs block the cyclooxygenase enzymes responsible for prostaglandin production and reduce the incidence of PCME after cataract surgery. Nepafenac seems superior to other NSAIDs in terms of ocular penetration allowing higher and sustained therapeutic levels in retina and choroid. Topical steroids are less effective and may cause intraocular pressure increase limiting their long-term use. Nepafenac is cost effective, when the burden of PCME prevention is compared with the burden of treatment. Prevention is much cheaper and less harmful than invasive treatments like periocular or intravitreal injections. Overall, both nepafenac 0.1% and nepafenac 0.3% are well tolerated. They should be used carefully in patients with compromised corneas such as those with severe dry eye or penetrating grafts. If otherwise healthy cataract patients have ≥2 risk factors, like PCME in the other eye or posterior capsule rupture during surgery, treatment should be considered. Once-daily nepafenac 0.3% dosing may improve postoperative outcomes through increased patient compliance and may reduce treatment burden further. Every patient should be assessed in terms of risks/benefits of the treatment, in individual basis, before cataract surgery.