The role of NSAIDs in the management of postoperative ophthalmic inflammation

Pattern of Preferred Cataract Surgery Practices in Morocco: A Survey-Based Study

Aim and methodology The aim of the study was to describe the preferred cataract surgery practices among Moroccan ophthalmologists and compare them with practices in other countries. An online survey consisting of 29 multiple-choice questions was sent to Moroccan ophthalmologists. The questions were centered on the preferred cataract surgical practices of the participants. All the data obtained were collected and analyzed. Results A total of 276 participants responded to the survey. Of these, 178 (64,50%) were in the age group of 31-50 years. The visual acuity for which the operative indication was made was 4/10 for 144 (52.4%) participants). The most popular type of anesthesia was topical, reported by 172 (62.4%). Stop-and-chop was the most used technique for routine cataract surgeries, while hydroprolapse of the nucleus was the leading technique for soft cataracts. The two measures are considered crucial for postoperative endophthalmitis prophylaxis: Povidone-iodine instillation into the conjunctival sac and intracameral antibiotics were performed by 267 (97%) and 276 (100%) participants, respectively. Nonsteroidal anti-inflammatory drugs were prescribed by only 128 (46.5%) surgeons. Conclusion This study provides some insight into the present cataract surgery techniques in Morocco, which might differ considerably from one country to another. Studies in various countries need to be undertaken to develop a consensus and reach some evidence-based patterns. This study may serve as a guide for young surgeons starting their careers based on what the standard procedures are among their seniors and peers.

Ocular Pharmacology and Toxicology of TRPV1 Antagonist SAF312 (Libvatrep)

Purpose

To evaluate the pharmacology and toxicology of SAF312, a transient receptor potential vanilloid 1 (TRPV1) antagonist.

Methods

TRPV1 expression in human ocular tissues was evaluated with immunohistochemistry. Inhibition of calcium influx in Chinese hamster ovary (CHO) cells expressing human TRPV1 (hTRPV1) and selectivity of SAF312 were assessed by a fluorescent imaging plate reader assay. Ocular tissue and plasma pharmacokinetics (PK) were assessed following a single topical ocular dose of SAF312 (0.5%, 1.0%, 1.5%, 2.5%) in rabbits. Safety and tolerability of SAF312 were evaluated in rabbits and dogs. Effects of SAF312 on corneal wound healing after photorefractive keratectomy (PRK) surgery were assessed in rabbits.

Results

TRPV1 expression was noted in human cornea and conjunctiva. SAF312 inhibited calcium influx in CHO-hTRPV1 cells induced by pH 5.5 (2-[N-morpholino] ethanesulfonic acid), N-arachidonoylethanolamine, capsaicin, and N-arachidonoyl dopamine, with IC50 values of 5, 10, 12, and 27 nM, respectively, and inhibition appeared noncompetitive. SAF312 demonstrated high selectivity for TRPV1 (>149-fold) over other TRP channels. PK analysis showed highest concentrations of SAF312 in cornea and conjunctiva. SAF312 was found to be safe and well tolerated in rabbits and dogs up to the highest feasible concentration of 2.5%. No delay in wound healing after PRK was observed.

Conclusions

SAF312 is a potent, selective, and noncompetitive antagonist of hTRPV1 with an acceptable preclinical safety profile for use in future clinical trials.

Translational Relevance

SAF312, which was safe and well tolerated without causing delay in wound healing after PRK in rabbits, may be a potential therapeutic agent for ocular surface pain.

Investigating the associations of macular edema in retinitis pigmentosa

Macular edema (ME), the accumulation of intraretinal fluid in the macula, is a common sight affecting sequelae of retinitis pigmentosa (RP). However, it is unclear why some patients develop ME, and others do not. This study aims to identify associations between clinical-genetic factors in RP with ME. Patients with clinically confirmed RP cases were identified from the inherited retinal disease database at a large tertiary referral academic center. Demographic and genetic testing findings were noted. Additionally, optical coherence tomography volume scans were graded using a validated grading system. One hundred and six patients (73.1%) were found to have ME in at least one eye (OD = 88, mean = 37.9%, OS = 98, mean = 31.7%). Structurally, the presence of epiretinal membrane (ERM) (p < 0.007) and vitreo-macular traction (VMT) (p < 0.003) were significantly associated with ME. Additionally, X-linked (p < 0.032) and autosomal dominant inheritance (p < 0.039) demonstrated a significant association with ME, with RP1 (p < 0.045) and EYS (p < 0.017) pathogenic variants also significantly associated with ME. This study, in a large cohort of RP patients, confirms previous retinal structural associations for ME in RP and identifies potential new genetic associations.

Comparison of postcataract surgery anti-inflammatory regimens on the incidence of cystoid macular edema, iritis, pain, and photophobia

PURPOSE

To compare postcataract surgery anti-inflammatory regimens of intracanalicular dexamethasone insert and topical bromfenac on the incidence of cystoid macular edema (CME), iritis, pain, and photophobia.

SETTING

Eyes of York Cataract & Laser Center, York, Pennsylvania.

DESIGN

Retrospective chart review.

METHODS

Case records of 647 consecutive patients (1001 eyes) who underwent cataract surgery and received dexamethasone intracanalicular insert 0.4 mg (Group 1; 482 eyes) or topical nonsteroidal anti-inflammatory drug (NSAID) (bromfenac 0.075% 2 times a day) for 4 weeks postoperatively (Group 2; 519 eyes) were included. Both groups received intracameral moxifloxacin and phenylephrine/ketorolac. Patients with prior CME, vitreomacular traction, combined cataract/glaucoma surgery, and medication protocols different from those examined in this study were excluded.

RESULTS

Compared with the dexamethasone insert group, the topical NSAID group had a significantly lower incidence of CME (0.4% [2/519] vs 3.9% [19/482], P < .001) and photophobia (1.9% [10/519] vs 4.8% [23/482], P = .012). The incidence of breakthrough iritis (3.5% [18/519] vs 5.6% [27/482], P = .104) and pain also trended lower (4.0% [21/519] vs 5.4% [26/482], P = .314) in the topical NSAID group.

CONCLUSIONS

Topical NSAIDs were found to be more effective in controlling CME, pain, iritis, and photophobia after cataract surgery compared with the intracanalicular dexamethasone insert in the presence of intracameral phenylephrine/ketorolac.

Safety of the bag-in-the-lens implantation regarding the development of clinically significant pseudophakic cystoid macular edema: A retrospective case series study

PURPOSE

To determine the incidence of clinically significant pseudophakic cystoid macular edema (CSPME) after phacoemulsification using the 'bag-in-the-lens' lens (BIL) implantation technique and to examine the influence of associated risk factors for clinically significant pseudophakic macular edema (CSPME), both ocular and systemic.

METHODS

This retrospective study included 2419 first-operated eyes of 2419 adults who underwent phacoemulsification cataract surgery using the BIL implantation technique between January 2013 and December 2018 in the Antwerp University Hospital, Belgium. The significance of several risk factors (age, gender, previous history, intra- and postoperative complications) was examined by extraction of electronic medical files.

RESULTS

The 3-month incidence of CSPME in the subgroup without risk factors was 0.00% (95% CI: 0.00 -NA). The 3-month incidence of CSPME in the subgroup with risk factors was 0.57% (95% CI 0.22-1.29%). The 3-month incidence of CSPME in the total population of 2419 patients was 0.29% (95% CI: 0.11-0.65%). The risk factors most significantly associated with CSPME included renal insufficiency (hazard ration [HR]: 5.42; 95% CI: 1.69-17.44; P = .014), exudative age-related macular degeneration (HR: 74.50, 95% CI: 25.75-215.6; P < .001) and retinal vein occlusion (HR: 22.48, 95% CI: 4.55-111.02; P = .005).

CONCLUSIONS

In the absence of risk factors, the incidence of CSPME was zero. We can conclude that Primary Posterior Continuous Curvilinear Capsulorhexis (PPCCC) does not increase the risk for CSPME. Non-inferiority of the BIL implantation regarding the development of CSPME, relative to the traditional 'lens-in-the-bag' (LIB) implantation, confirms that BIL is a safe surgical technique. This study also illustrates a previously undescribed risk factor for developing CSPME, namely renal insufficiency.

The Immediate Early Response of Lens Epithelial Cells to Lens Injury

Cataracts are treated by lens fiber cell removal followed by intraocular lens (IOL) implantation into the lens capsule. While effective, this procedure leaves behind numerous lens epithelial cells (LECs) which undergo a wound healing response that frequently leads to posterior capsular opacification (PCO). In order to elucidate the acute response of LECs to lens fiber cell removal which models cataract surgery (post cataract surgery, PCS), RNA-seq was conducted on LECs derived from wild type mice at 0 and 6 h PCS. This analysis found that LECs upregulate the expression of numerous proinflammatory cytokines and profibrotic regulators by 6 h PCS suggesting rapid priming of pathways leading to inflammation and fibrosis PCS. LECs also highly upregulate the expression of numerous immediate early transcription factors (IETFs) by 6 h PCS and immunolocalization found elevated levels of these proteins by 3 h PCS, and this was preceded by the phosphorylation of ERK1/2 in injured LECs. Egr1 and FosB were among the highest expressed of these factors and qRT-PCR revealed that they also upregulate in explanted mouse lens epithelia suggesting potential roles in the LEC injury response. Analysis of lenses lacking either Egr1 or FosB revealed that both genes may regulate a portion of the acute LEC injury response, although neither gene was essential for expression of either proinflammatory or fibrotic markers at later times PCS suggesting that IETFs may work in concert to mediate the LEC injury response following cataract surgery.

Experimental design approach, screening and optimization of system variables, analytical method development of flurbiprofen in nanoparticles and stability-indicating methods for high-pressure liquid chromatography

Background

The development of chromatographic method and the validation of a sensitive, simple, efficient, and reversed-phase high-performance liquid chromatography (RP-HPLC) approach were adopted for the drug flurbiprofen (FBP) in nanoparticles formulation by using a design of experiment (DoE). The critical method variables (CMVs) were screened using a statistical two-level fractional factorial design (FFD) followed by optimization of the selected CMVs that influence the analytical responses (ARs) of the RP-HPLC process by using two-level full factorial design.

Results

Statistical models are used to investigate the effects of system factors including column temperature, flow rate, and methanol in orthophosphoric acid (OPA) on the dependent responses, retention time, peak area, tailing factor, and theoretical plates in HPLC. The ideal column temperature (25 °C), flow rate (1 ml/min), and mobile phase (methanol 85 percent v/v in 0.05 percent OPA in water) were selected independently from the response surface at three levels (1, + 1, and 0) for further validation at constant solvent pH 2.75. Optimized method in the RP-HPLC resulted a retention time of 4.75 min, a peak area of 3975.12, a tailing factor of 0.73, and a total of 9697.7 theoretical plates followed by validation in accordance with the current ICH recommendations Q2 (R1). Linearity, precision, accuracy, assay, limit of detection (LOD), limit of quantification (LOQ), and robustness were all included in validation. The calibration curve was linear (r2 = 0.9997, slope = 70.72) for the concentration of 10 to 50 µg/ml, with a limit of detection of 0.14 µg/ml. Furthermore, stability-indicating methods demonstrate that drug degradation is highest in the presence of basic circumstances (about 96.49%), followed by oxidation (about 76.41%), and acidic conditions (about 48.12%), whereas drug is stable in some extent under neutral, photo (sunlight), and dry heat conditions.

Conclusions

Effect of independent variables on dependent responses was screened and optimized by using statistical software design. A method for drug development could be successfully implemented for the estimation of drug in nanoparticles formulation as well as for the routine analysis in bulk and pharmaceutical formulations. The high recovery and low relative standard deviation support the suitability of proposed method that could be employed.

Graphical Abstract

Advances in ophthalmic drug delivery technology for postoperative management after cataract surgery

INTRODUCTION

Cataract surgery is becoming more common due to an aging world population. Intraocular lenses and surgical technique have developed remarkably recently, but the development of postoperative medication to prevent postsurgery complications has been relatively delayed. We still largely depend on eye drops for the management of post-cataract-surgery patients. Mental and physical problems that often occur in elderly cataract patients make it difficult for patients to apply eye drops by themselves. It is necessary to develop new effective drug delivery methods.

AREAS COVERED

This updated review article provides a brief review of why drug management is needed following cataract surgery and an overview of current developments in new drug delivery methods for ophthalmic treatment. In particular, various novel drug delivery methods that can be used for post-cataract-surgery management and their current development stages are extensively reviewed.

EXPERT OPINION

Rapidly developing technologies, such as intraocular and external ophthalmic implants, polymers, and nanotechnology, are being actively applied to develop novel drug delivery systems for safe and effective management after cataract surgery. Their goal is to achieve sufficient drug release for the desired duration with a single application. These will largely replace the inconvenience of eye drops for elderly patients in the future.

Comparison of once daily dose of 0.3% nepafenac alone and three times dose of 0.1% nepafenac alone in pain and inflammation control after phacoemulsification

Purpose:

To compare the efficacy of a once-daily dose of 0.3% nepafenac and three times daily dose of 0.1% nepafenac in controlling pain and inflammation following phacoemulsification.

Methods:

In this prospective randomized control single-blind study. patients who underwent uneventful phacoemulsification were divided into two groups. Group A received 0.1% nepafenac eye drops three times/day for 4 weeks and group B received 0.3% nepafenac eye drops once daily for 4 weeks following phacoemulsification. All the patients received moxifloxacin 0.5% eye drops four times/day for 2 weeks. None of the patients in any group received any form of corticosteroids.

Results:

The mean age of the patients in group A was 63.55 ± 8.5 years, while in group B, it was 60.05 ± 7.76 years. There was no significant result in the preoperative baseline demographics and intraoperative parameters between both the groups. The results were statistically insignificant in terms of inflammatory markers between both groups on day 1. But, on day 7, group B showed better results in terms of lid edema, conjunctival congestion, and anterior chamber cells. The patients in group B also perceived significantly less pain on day 1 (P = 0.02) and day 7 (P < 0.001). The central macular thickness was also significantly lower in group B at day 30 (P < .001) and day 90 (P < .001), respectively.

Conclusion:

Once-daily dose of higher concentrated nepafenac (0.3%) is equally effective and shows better results than 0.1% nepafenac for pain and inflammation control.

A Post-Acute Ocular Tolerability Comparison of Topical Reproxalap 0.25% and Lifitegrast 5% in Patients with Dry Eye Disease

Purpose

To assess the subjective eye drop experience of patients with dry eye disease (DED) over approximately 1 hour after a single dose of two formulations of reproxalap versus lifitegrast.

Methods

Two formulations of topical ocular reproxalap 0.25% were evaluated versus lifitegrast ophthalmic solution 5% in patients with DED in a single-center, double-masked, active-comparator, single-dose crossover clinical trial. Nineteen patients had test article topically administered to both eyes. Treatments were administered 2 to 4 days apart. Comfort assessments, including ocular discomfort, blurry vision, and dysgeusia assessments; ocular descriptive assessments; quality of life assessments; and overall experience questions were completed after each treatment over one hour, beginning at 90 seconds.

Results

Both reproxalap formulations scored better in ocular discomfort score (ODS), blurry vision, and dysgeusia assessments than lifitegrast at each timepoint and cumulatively over all time points after instillation. There were lower rates of negative responses for both reproxalap formulations compared to lifitegrast across ocular discomfort, blurry vision, and dysgeusia assessments, and the durations of negative responses were shorter with reproxalap than with lifitegrast. The reproxalap groups experienced fewer quality of life impacts. No significant safety findings were observed following reproxalap or lifitegrast administration.

Conclusion

The reproxalap eye drop experience over 1 hour after instillation was superior to that of lifitegrast. There were no statistically significant differences between reproxalap groups for ODS, blurry vision, or dysgeusia. The improved performance of reproxalap with regard to the most commonly reported side effects of lifitegrast (ie, ocular discomfort, blurry vision, and dysgeusia) may result in greater patient adherence and lower discontinuation rates.

Prednisolone and Ketorolac vs Ketorolac Monotherapy or Sub-Tenon Prophylaxis for Macular Thickening in Cataract Surgery: A Randomized Clinical Trial

Question

Is a combination of corticosteroid and nonsteroidal anti-inflammatory drug (NSAID) eye drops superior to NSAID eye drops alone or dropless surgery with a sub-Tenon dexamethasone depot in controlling postoperative central macular thickening after uncomplicated cataract surgery?

Findings

In this randomized clinical trial with 470 participants, no differences in central subfield thickness or visual acuity across treatment arms were identified, although approximately half of the group given the sub-Tenon depot received additional anti-inflammatory treatment.

Meaning

Therapy with NSAID plus corticosteroid eye drops was not superior to NSAID monotherapy or sub-Tenon depot for postoperative central macular thickening after uncomplicated cataract surgery.

Importance

The choice of anti-inflammatory prophylaxis parallel to cataract surgery is important for patient safety and successful outcome of surgery, but which regimen to choose is contested.

Objectives

To determine whether a combination of prednisolone and nonsteroidal anti-inflammatory drug (NSAID) eye drops was superior in preventing increased central macular thickness (central subfield thickness [CST]) after uncomplicated cataract surgery compared with NSAID monotherapy and sub-Tenon capsule depot (dropless surgery), and to test whether preoperative initiation of eye drop treatment was superior to initiation on the day of surgery.

Design, Setting, and Participants

This investigator-driven, single-center, randomized clinical trial with masked statistical analyses enrolled patients at the Department of Ophthalmology, Rigshospitalet Glostrup, Glostrup, Denmark, from February 1, 2018, to August 15, 2019. Follow-up was completed December 18, 2019. Participants included low-risk patients undergoing phacoemulsification for age-related cataract by an experienced surgeon (1 eye per participant). Data were analyzed from February 17 to June 15, 2020.

Interventions

Participants scheduled for cataract removal were randomized to 1 of 5 anti-inflammatory prophylactic regimens: eye drops with a combination of prednisolone, 1%, and ketorolac tromethamine, 0.5%, with or without preoperative initiation (preoperative prednisolone plus NSAID [control] and postoperative prednisolone plus NSAID groups), ketorolac monotherapy with or without preoperative initiation (preoperative and postoperative NSAID groups), or sub-Tenon depot of dexamethasone phosphate (sub-Tenon group). Eye drops were administered 3 times per day until 3 weeks postoperatively.

Main Outcomes and Measures

CST 3 months postoperatively.

Results

A total of 470 participants (mean [SD] age, 72.2 [7.0] years; 290 women [61.7%]) with 94 participants in each group were included in the analysis. Three months after surgery, the mean CST was 250.7 (95% CI, 247.6-253.7) μm in the preoperative prednisolone plus NSAID group, 250.7 (95% CI, 247.8-253.7) μm in the postoperative prednisolone plus NSAID group, 251.3 (95% CI, 248.2-254.4) μm in the preoperative NSAID group, 249.2 (95% CI, 246.2-252.3) μm in the postoperative NSAID group, and 255.2 (95% CI, 252.0-258.3) μm in the sub-Tenon group. There were no significant differences in CST or visual acuity compared with control and no differences between preoperative and postoperative groups, but 47 of 83 participants (56.6%) in the sub-Tenon group needed additional anti-inflammatory treatment.

Conclusions and Relevance

No differences in CST or visual acuity were detected between the combination of prednisolone and NSAID eye drops vs NSAID monotherapy or sub-Tenon dexamethasone depot, although more than one-half of patients in the sub-Tenon arm received additional anti-inflammatory treatment. Initiating prophylaxis 3 days preoperatively was not superior to initiation on the day of surgery. Monotherapy with NSAIDs may be preferred in uncomplicated cataract surgery.

Trial Registration

ClinicalTrials.gov Identifier: NCT03383328

A Novel Indomethacin-Tripeptide Hydrogel for Inhibiting Ocular Inflammation

A highly efficient method for constructing indomethacin-peptide conjugates was developed using the natural amino acid tyrosine (Y) as the anchor for indomethacin (Idm). With pH = 6, Idm-YEE conjugate self-assembled in a low critical micelle concentration (CMC, 0.037 mg/mL) and formed a transparent hydrogel (0.4 wt%). The formed Idm-YEE hydrogel presented sustained drug release of indomethacin with a maximum of 40% during first 24 hours, which was superior to the reported Idm-containing supramolecular hydrogel systems. As kept at 4 °C, the Idm-YEE hydrogel showed good storage stability up to 30 days without obvious hydrolysis. As shown by MTT assay, the Idm-YEE hydrogel exhibited good cell compatibility against retinal pigment epithelial cells (ARPE-19) and Human corneal epithelial cells (HCEC). Ocular irritation test (i.e., clinical observations, fluorescein staining and H&E histological analysis) results showed good integrity of corneal architecture and no edema after Idm-YEE hydrogel treatment, which proved its good ocular biocompatibility. Besides, the LPS-stimulated levels of key inflammatory mediators, including NO, PGE₂ and IL-6, were greatly reduced by Idm-YEE hydrogel even in a low concentration (50 μM) in Raw264.7 cells, which indicated its comparable in vitro anti-inflammatory activity to indomethacin. Furthermore, the therapeutic efficacy of Idm-YEE hydrogel was evaluated in endotoxin-induced uveitis (EIU) rabbit model. By treating with dm-YEE hydrogel, the rabbit eyes had significantly lowered inflammation and exudation in the anterior chamber. The results of histological analysis, clinical score, inflammatory cell counts, aqueous protein concentration and immunohistochemical staining also demonstrated its good in vivo therapeutic activity towards ocular inflammation. Therefore, with good ocular biocompatibility and comparable anti-inflammatory effect towards ocular inflammation, the novel indomethacin-tripeptide hydrogel (Idm-YEE) developed in this work provides a potential treatment for anterior uveitis.

Effect of anti-inflammatory regimen on early postoperative inflammation after cataract surgery

PURPOSE

To investigate whether a combination of topical nonsteroidal anti-inflammatory drugs (NSAIDs) and steroids were superior in controlling early postoperative inflammation after cataract surgery compared with topical NSAIDs alone and with dropless surgery where a sub-Tenon depot of steroid was placed during surgery.

SETTING

Department of Ophthalmology, Rigshospitalet-Glostrup, Denmark.

DESIGN

Prospective randomized controlled trial with masked statistical analyses.

METHODS

Patients undergoing phacoemulsification for age-related cataract were randomized to 1 of 5 regimens: ketorolac and prednisolone eyedrops combined (Pred+NSAID-Pre [control group] and Pred+NSAID-Post group) vs ketorolac monotherapy (NSAID-Pre and NSAID-Post groups) vs sub-Tenon depot of dexamethasone (dropless group). Drops were used until 3 weeks postoperatively, starting 3 days preoperatively in the Pre groups and on the day of surgery in the Post groups. Aqueous flare was measured at baseline and 3 days postoperatively.

RESULTS

Four hundred fifty-six participants, with a mean age of 72.1 (SD 7.0) years and 283 (62%) women, were included. Flare increased significantly more in the dropless group compared with the control group (Pred+NSAID-Pre), but none of the other groups differed significantly from the control group. Intraocular pressure decreased in all groups but significantly less in groups receiving prednisolone eyedrops (Pred+NSAID-Pre and Pred+NSAID-Post groups) compared with NSAID monotherapy and dropless groups. No differences in postoperative visual acuity were found compared with the control group.

CONCLUSIONS

No differences were found between groups randomized to NSAID monotherapy or combination of NSAID and steroid in controlling early inflammation after cataract surgery, but sub-Tenon depot of dexamethasone was less efficient. Initiating prophylactic eyedrops prior to surgery did not influence early postoperative anterior chamber inflammation.

Ocular Neuropathic Pain: An Overview Focusing on Ocular Surface Pains

Objective

This paper reviews ocular pain with the main focus on ocular surface discomfort and dry eye pain. Anatomy, physiology, epidemiology, assessment, and treatment are discussed in this paper.

Methods

A PubMed search was conducted for studies published from 2000 to 2019 on the anatomy, pathophysiology, epidemiology, assessment, and treatment of ocular pain. Reviews, meta-analyses, and randomized clinical trials were included. Inclusion criteria focused on ocular surface discomfort, dry eye pain and neuropathic pain.

Results

A total of 112 articles were found through searches, 45 of which were selected and studied in this review.

Discussion

Pain in general can be acute or chronic. Acute pain is usually a physiologic response to a serious damage to the tissues and alleviates with pain relief treatments. Chronic pain is defined as the persistence of pain for more than three months. From another point of view, pain has been classified into either nociceptive or neuropathic. Nociceptive pain is a physiologic response to a noxious stimulus. Both central and peripheral nervous systems can be involved in the development of a neuropathic pain, which is characterized by positive or negative sensory signs, a pain perceived disproportionate to a noxious stimulus, and/or not responsive to analgesics. Chronic pain usually has a neuropathic component. Ocular surface pain is a well-known complaint after any corneal surgery. This is mainly due to abnormal regeneration of damaged corneal nerve endings and abnormal connections with adjacent nerve endings which produce spontaneous activity. Tear hyperosmolarity and the resultant ocular surface inflammation can also trigger voluntary activity of corneal nerve endings. Referral pain to the first and second division of the trigeminal nerve has been reported. Interference with vision and even sleep, which is out of proportion to the examination are among patients' complaints. All of these elements proposed the new concept of ocular neuropathic pain syndrome. The first step in conventional evaluation of ocular discomfort is search for tear insufficiency. Pathologies of lid and blinking as well as conjunctival irregularities should be addressed. Anti-inflammatory agents and, in resistant cases, systemic neuromodulators are shown to be helpful. Education on behavioral changes and reassurance are essential steps. Considering the neuropathic origin for the ocular pain, treatment modalities used for such pain in other parts of the body can be considered for this syndrome.

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.

Clinically significant pseudophakic cystoid macular edema after bag-in-the-lens implantation

PURPOSE

To determine the incidence of clinically significant pseudophakic cystoid macular edema (CSPME) after phacoemulsification using the bag-in-the-lens intraocular lens (BIL IOL) implantation technique and to examine the influence of associated risk factors, both ocular and systemic.

SETTING

Monocentric, Antwerp University Hospital, Belgium.

DESIGN

Retrospective.

METHODS

This study included 1 077 first-operated eyes of 1 077 adults who underwent phaco-emulsification cataract surgery using the BIL IOL implantation technique between January 2013 and December 2015.

RESULTS

The 3-month incidence of CSPME in the subgroup without risk factors was 0% (95% CI, 0.0-0.0). The 3-month incidence of CSPME in the subgroup with risk factors was 2.8% (95% CI, 1.3-4.3). The 3-month incidence of CSPME in the total group of 1077 patients was 1.4% (95% CI, 0.6-2.1). The risk factors most significantly associated with CSPME included diabetes (hazard ratio [HR]: 5.37; 95% CI, 1.5-19.3; P = .019), exudative age-related macular degeneration (HR: 121; 95% CI, 36.1-409; P < .001), and macular traction (HR: 6.47; 95% CI, 1.9-22.1; P < .009).

CONCLUSIONS

The incidence of CSPME was zero in eyes without risk factors. The incidence was consistent with previous reports in the literature regarding the lens-in-the-bag IOL implantation technique in eyes with risk factors. This indicates that the BIL IOL implantation technique is a safe procedure and does not confer a higher risk for developing cystoid macular edema after cataract surgery compared with the lens-in-the-bag IOL implantation technique, despite the requirement of a primary posterior continuous curvilinear capsulorhexis.

Eudragit RL100 Based Moxifloxacin Hydrochloride and Ketorolac Tromethamine Combination Nanoparticulate System for Ocular Drug Delivery

BACKGROUND

Bacterial conjunctivitis is a serious ocular infection if left untreated. It is caused by several species of bacteria like Pseudomonas, Staphylococcus and Mycobacterium.

OBJECTIVE

The present investigation explores the development and characterization of moxifloxacin hydrochloride and ketorolac tromethamine combination loaded Eudragit RL 100 nanosuspension for ocular drug delivery in order to overcome the problems associated with conventional dosage forms.

METHODS

The nanosuspension prepared by nanoprecipitation technique showed successful entrapment of both water-soluble drugs in the polymer matrix indicated by their % entrapment efficiencies.

RESULTS

Formulations showed a mean particle size <200 nm with narrow size distribution and positive surface charge due to the presence of quaternary ammonium groups of Eudragit RL100. FTIR study revealed compatibility among the components, while a reduction in the crystallinity of formulation was observed in the PXRD study. The release of both the drugs was found to be sustained in nanosuspension as compared to commercial eyedrops. Ex vivo studies showed increased transcorneal permeation of drugs from nanosuspension, where approximately 2.5-fold and 2-fold increase in the permeation was observed for moxifloxacin hydrochloride and ketorolac tromethamine, respectively. The formulation was stable at 4°C and room temperature.

CONCLUSION

Due to their sustained release, positive surface charge and higher transcorneal permeation, this will be a promising ocular drug delivery.

Management of Postoperative Inflammation and Dry Eye After Cataract Surgery

Surgical intervention is the most effective treatment for decreased vision resulting from cataracts. Although the current procedures for cataract surgery are safe and effective, it is well known that several complications can develop after surgery. Postoperative cystoid macular edema (CME) is a well-known complication, and prophylactic medications such as steroids and/or nonsteroidal antiinflammatory drugs are routinely used for its prevention. Ocular surface abnormalities, such as dry eye, have also been reported to develop after cataract surgery. However, the causative mechanisms for postoperative dry eye have not been definitively determined. At present, there are no prophylactic medications that are commonly used to prevent the development of postoperative dry eye. Although nonsteroidal antiinflammatory drugs are very effective in reducing the incidence and degree of postoperative CME, it is known that they can cause adverse side effects, including ocular surface abnormalities. Thus, perioperative medications must be carefully selected to improve surgical outcomes and patient satisfaction. Here, we summarize the results of recent studies on postoperative dry eye and CME that can develop after cataract surgery. We suggest appropriate combinations of medications that can be used to minimize these postsurgical complications.

Treatment of cystoid macular edema after cataract surgery

The purpose of this review was to determine the optimum pharmacologic treatment for cystoid macular edema (CME) after cataract surgery in nondiabetic and diabetic patients. The Cochrane Library, Medline, and Embase databases were searched, and all randomized controlled trials (RCTs) that compared at least 2 pharmacologic strategies for CME after cataract surgery were included. Studies were excluded if preoperative CME or other risk factors for developing CME postoperatively were present. Ten RCTs were included in the systematic review. Five trials included at least 30 participants. Three RCTs showed a greater visual acuity improvement in patients treated with topical nonsteroidal antiinflammatory drugs (NSAIDs) than with a placebo. Other studies comparing the efficacy of topical NSAIDs, topical corticosteroids, sub-Tenon corticosteroids, oral NSAIDs, and oral acetazolamide did not report significant differences between treatment groups. Therefore, large RCTs are needed to provide evidence-based recommendations for the optimum treatment of CME after cataract surgery.

Effect Of Intracameral Phenylephrine And Ketorolac 1.0%/0.3% On Intraoperative Pain And Opioid Use During Cataract Surgery

Purpose

To compare the effect of Omidria (phenylephrine and ketorolac 1.0%/0.3%) vs epinephrine on pain reduction and opioid usage during cataract surgery.

Patients and methods

Sixty patients at a single center underwent femtosecond laser (FLACS) or conventional phacoemulsification under topical lidocaine gel anesthesia and intracameral preservative-free lidocaine 1%. Eligible participants were prospectively assigned to receive either intracameral phenylephrine and ketorolac 1.0%/0.3% or intracameral epinephrine. All patients received standardized pre- and post-operative topical therapy. Intravenous (IV) fentanyl was administered for ocular discomfort in patients who complained of intraoperative pain. Outcome measures included both pain (measured by mean visual analog scale (VAS) pain scores from 0 (no pain) to 10 (extreme pain)) and the use of IV fentanyl during surgery. A composite endpoint identified “responders” as being patients who: (1) did not require fentanyl and (2) experienced no to minimal pain (VAS score ≤ 3).

Results

Forty-one patients were in the phenylephrine and ketorolac 1.0%/0.3% (study) group and 19 were in the epinephrine (control) group. Mean VAS pain scores were significantly (48.9%) lower in the study group than the control group (2.3 vs 4.5; P < 0.0001). The proportion of patients with VAS scores ≤ 3 was significantly greater in the study group (85.0%) than the control group (31.6%) (P < 0.0001). A smaller proportion of patients required intraoperative fentanyl in the study group compared to the control group (9.8% vs 42.1%; P = 0.006). For the composite endpoint, patients receiving phenylephrine and ketorolac 1.0%/0.3% were 94% less likely to require fentanyl or to have moderate-to-severe pain (pain VAS ≥ 4; OR, 0.06; 95% CI 0.02–0.24) than patients receiving epinephrine.

Conclusion

Our results suggest that the routine use of intracameral phenylephrine and ketorolac 1.0%/0.3% during cataract surgery can significantly reduce patient pain as well as the need for opioids.

Cataract surgeon viewpoints on the need for novel preventative anti-inflammatory and anti-posterior capsular opacification therapies

Purpose: To determine cataract surgeon viewpoints on the efficacy of available therapies/preventatives for two common sequelae of cataract surgery: inflammation and posterior capsular opacification (PCO). Methods: Cataract surgeons practicing worldwide specializing in adult, pediatric and veterinary patients were interviewed between March and August 2018. Results: Ocular inflammation following cataract surgery is treated by either corticosteroids and/or nonsteroidal anti-inflammatories (NSAIDs). Adult and pediatric cataract surgeons are satisfied with current treatments whereas this inflammation is still considered a problem by some in veterinary practice due to its slow resolution. Yttrium-aluminum-garnet (YAG) laser therapy is the PCO treatment of choice for adult cataract surgeons and they are generally pleased with its outcome. However, pediatric cataract surgeons find YAG problematic, especially in patients under 6 years of age, and invasive surgery is often needed to correct PCO/visual axis opacification (VAO). Veterinary ophthalmologists report that YAG is not effective for PCO in animals, especially dogs, due to the density of the fibrotic plaques; 86% of adult and 100% of veterinary and pediatric cataract surgeons surveyed agree that effective anti-PCO therapeutics would improve clinical care. Conclusions: Surgeons treating human patients are pleased with the available treatments for ocular inflammation following cataract surgery, although some veterinary ophthalmologists disagree. The surgeons surveyed agree that PCO/VAO remains an unsolved problem in pediatric and veterinary cataract surgery while the long-term outcome of adult cataract surgery could be improved by additional attention to this issue.

Quantification of Inflammation Following Nd:YAG Laser Capsulotomy and Assessing the Anti-inflammatory Effects of Nepafenac 0.1% and Betamethasone 0.1

Purpose: To quantify the intraocular inflammation, measured using laser flare photometry (LFP), after Nd:YAG capsulotomy and compare the effects of different topical anti-inflammatory regimes.Methods: A single-center, prospective, randomized controlled study, which included 90 eyes of 90 patients with visually significant posterior capsular opacification. In all patients, Nd:YAG capsulotomy was done and was then randomized into three groups: (A) Topical betamethasone 0.1%; (B) Topical nepafenac 0.1%; and (C) Control group: did not receive any anti-inflammatory agent post capsulotomy.Results: There was a significant increase in the mean LFP values 2 h following laser capsulotomy (p < 0.001) and then declined gradually and came back to pre-laser values by 2 weeks in all three groups. The mean LFP values, central macular thickness, and best corrected visual acuity were comparable among groups. None developed central macular edema.Conclusion: Intraocular inflammation following Nd:YAG capsulotomies is minimal and transient. Routine use of prophylactic anti-inflammatory agents may be avoided.

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.

An ex vivo human aqueous humor-concentration comparison of two commercial bromfenac formulations

Purpose

The purpose of this study was to quantify the concentration of bromfenac in the aqueous humor utilizing high-performance liquid chromatography mass spectrometry between two commercial nonsteroidal anti-inflammatory drugs, using aqueous humor concentrations to characterize pharmacokinetic proportional differences between 0.075% bromfenac ophthalmic solution in DuraSite (BromSite^®) and 0.09% bromfenac ophthalmic solution (Bromday^®).

Methods

In this multicenter, randomized, double-masked, two-arm, parallel-group, comparative, Phase II clinical trial, subjects were assigned to receive bromfenac in DuraSite or bromfenac ophthalmic solution in a 1:1 ratio. One drop of the masked test article was instilled into the study eye once a day for 2 days prior to and 3 hours prior (last instillation) to the subject's cataract surgery. Aqueous humor samples were collected upon initial cataract incision for analysis of bromfenac levels. The primary end point was aqueous humor concentration of bromfenac at Day 3, at the initiation of cataract surgery. Aqueous humor samples were collected and analyzed for bromfenac levels.

Results

A total of 60 subjects completed the study, 30 in each group. The mean bromfenac aqueous humor concentration in subjects who received bromfenac in DuraSite was more than twice (49.33±41.87 ng/mL, P=0.004) that of subjects who received bromfenac ophthalmic solution (23.65±16.31 ng/mL) after three doses.

Conclusion

Mean bromfenac aqueous humor concentration in subjects receiving the DuraSite-containing bromfenac in DuraSite (0.075%) was significantly higher compared to subjects receiving bromfenac ophthalmic solution (0.09%) after 3 days of dosing.

In Vivo Pharmacokinetics of Bromfenac Ophthalmic Solution 0.075%, Bromfenac Ophthalmic Solution 0.07%, and Nepafenac/Amfenac Ophthalmic Suspension 0.3% in Rabbits

Introduction

Little is known of the ocular distribution characteristics of currently branded non-steroidal anti-inflammatory drugs (NSAIDs) in the United States. This study was designed to predict the ocular bioavailability characteristics in humans using Dutch Belted rabbits as a surrogate. Commercially available, topically-applied NSAIDs containing bromfenac or nepafenac/amfenac were evaluated.

Methods

126 healthy adult Dutch Belted rabbits were randomly assigned to three treatment cohorts (BromSite^® twice daily [BID] in the right eye, BromSite^® once daily [QD] in the right eye, Prolensa^® QD in the right eye and Ilevro™ QD in the left eye) and 7 post-dosing time points (0.5, 1, 2, 4, 8, 12, 24 h after final instillation). The study eyes received 40 µL of the assigned drug for a consecutive 9 days. Samples of aqueous humor, iris-ciliary body, choroid, sclera, and retina were harvested from the study eyes at the assigned time point after the last dose on the 9th day. NSAID content in ocular tissues was analyzed using high-performance liquid chromatography (HPLC), and area under the curve (AUC_0.5–24h), maximum concentration (C_max), and time to maximum concentration (T_max) were determined.

Results

Peak NSAID concentrations were reached within 1–3 h in the anterior segment and within 1–3 h in the posterior segment after last dose. Throughout the ocular tissues, both AUC and C_max for BromSite^® (BID and QD) were consistently higher than respective NSAID concentrations of Prolensa^® QD and Ilevro^® QD. When comparing BromSite^® BID to QD, the BID regimen produced generally higher but statistically similar bromfenac concentrations throughout the ocular tissues except in the aqueous humor and iris-ciliary body, where the AUC BID was statistically significantly higher with BromSite^® BID.

Conclusion

As a surrogate to human ocular bioavailability, BromSite^® demonstrated significantly greater NSAID compared to Prolensa^® QD and Ilevro^® QD. The DuraSite^® component of BromSite^® appears to enhance ocular penetration throughout both anterior and posterior tissues.

Funding

Sun Pharmaceutical Industries Ltd.

Visual outcomes, efficacy, and surgical complications associated with intracameral phenylephrine 1.0%/ketorolac 0.3% administered during cataract surgery

Aim

The purpose of this study was to compare visual outcomes, surgical time, and perioperative surgical complications after intracameral use of either phenylephrine/ketorolac (P/K) or epinephrine (Epi) during cataract surgery.

Methods

This was a single-center, retrospective case review of patients undergoing cataract surgery from August to November 2015. Of the 641 eyes of 389 patients who underwent cataract surgery, 260 eyes were administered phenylephrine 1.0%/ketorolac 0.3% and 381 eyes received Epi in the irrigation solution intraoperatively. All patients received a topical nonsteroidal anti-inflammatory drug regimen (bromfenac 0.07%, nepafenac 0.3%, or ketorolac 0.5%) for 3 days before surgery and topical tropicamide 1.0%, cyclopentolate 1.0%, and phenylephrine 2.5% on the day of surgery.

Results

Mean length of surgery (LOS) was 15.4±0.6 minutes. Although a positive correlation was noted between patient age and LOS (p<0.001), P/K was associated with a decrease in the LOS, when controlled for age quartiles. A statistically significant lower incidence of complications (1.1%) was observed with P/K use than Epi (4.5%; p=0.018). Among surgeons who used mydriatic-assist devices more frequently, P/K use was associated with a reduction in the use of these devices (p<0.001). When controlling for age quartile, patients of age groups 69–76 and 76–92 years who received P/K had significantly better uncorrected visual acuity at postoperative day 1 than those receiving Epi (p=0.003).

Conclusion

Intracameral use of phenylephrine 1.0%/ketorolac 0.3% during cataract surgery may be effective in maintaining mydriasis. It appears to be superior to intracameral Epi at reducing intraoperative and postoperative complications, need for pupillary dilating devices, and surgical time.

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.

Incidence and Risk Factors of Cystoid Macular Edema after Vitrectomy with Silicone Oil Tamponade for Retinal Detachment

PURPOSE

To investigate the incidence and risk factors of cystoid macular edema (CME) after silicone oil (SO) injection for retinal detachment.

METHODS

Fifty-eight patients with retinal detachment treated by vitrectomy with SO tamponade during 2011 to 2015 were retrospectively assigned to CME and non-CME groups. Patients underwent complete ophthalmological examination, including color fundus photography and preoperative and postoperative optical coherence tomography. Risk factors for CME during SO tamponade were determined by regression analyses.

RESULTS

Of the 58 eyes, 21 (36.2%) exhibited CME. The presence of posterior staphyloma in the CME group was significantly more frequent than in the non-CME group (p = 0.026). There were no significant differences in other demographic or clinical characteristics between the CME and non-CME groups. Significant correlations were observed between CME after vitrectomy with SO tamponade and the presence of posterior staphyloma (odds ratio, 4.03; p = 0.031). Of the 21 eyes with CME, 13 underwent SO removal, among which 11 experienced resolution of CME with or without further intervention.

CONCLUSIONS

The presence of posterior staphyloma is significantly associated with CME after vitrectomy with SO tamponade. Patients with retinal detachment exhibiting posterior staphyloma should be evaluated for potential CME during SO tamponade.

Conjunctival Goblet Cell Density Following Cataract Surgery With Diclofenac Versus Diclofenac and Rebamipide: A Randomized Trial

PURPOSE

To determine the effects of topical diclofenac or betamethasone with concomitant application of topical rebamipide on the conjunctival goblet cell density in eyes after cataract surgery.

DESIGN

Randomized clinical trial.

PARTICIPANTS

Eighty patients who were scheduled for cataract surgery.

METHODS

Patients were randomized into 4 groups according to the postoperative topical drugs to be given; Group A, diclofenac alone; Group B, diclofenac and rebamipide; Group C, betamethasone alone; and Group D, betamethasone and rebamipide. Impression cytology was performed before and at 1 month after the surgery, and the mean density of goblet cells was determined.

RESULTS

The mean (± SD) density of goblet cells before the surgery in Group A was 257.0 ± 188.7 cells/mm², and it decreased significantly to 86.5 ± 76.7 cells/mm² at 1 month after the surgery (P = .002). In Group B, the goblet cell density was not statistically different between before (238.5 ± 116.6 cells/mm²) and at 1 month after the surgery (211.3 ± 184.4 cells/mm², P = .55). In Groups C and D, the mean density of goblet cells was decreased at 1 month after the surgery, but the decreases were not significant (P = .11 and P = .52, respectively).

CONCLUSION

After cataract surgery with postoperative topical diclofenac, the conjunctival goblet cell density was significantly reduced, and this reduction was blocked by the concomitant use of topical rebamipide. These results suggest that the concomitant use of topical rebamipide with nonsteroidal anti-inflammatory drugs is beneficial, especially in cases with postoperative dry eyes.

Non-steroidal anti-inflammatory drugs versus corticosteroids for controlling inflammation after uncomplicated cataract surgery

BACKGROUND

Cataract is a leading cause of blindness worldwide. Cataract surgery is commonly performed but can result in postoperative inflammation of the eye. Inadequately controlled inflammation increases the risk of complications. Non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids are used to prevent and reduce inflammation following cataract surgery, but these two drug classes work by different mechanisms. Corticosteroids are effective, but NSAIDs may provide an additional benefit to reduce inflammation when given in combination with corticosteroids. A comparison of NSAIDs to corticosteroids alone or combination therapy with these two anti-inflammatory agents will help to determine the role of NSAIDs in controlling inflammation after routine cataract surgery.

OBJECTIVES

To evaluate the comparative effectiveness of topical NSAIDs (alone or in combination with topical corticosteroids) versus topical corticosteroids alone in controlling intraocular inflammation after uncomplicated phacoemulsification. To assess postoperative best-corrected visual acuity (BCVA), patient-reported discomfort, symptoms, or complications (such as elevation of IOP), and cost-effectiveness with the use of postoperative NSAIDs or corticosteroids.

SEARCH METHODS

To identify studies relevant to this review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), which contains the Cochrane Eyes and Vision Trials Register (2016, Issue 12), MEDLINE Ovid (1946 to December 2016), Embase Ovid (1947 to 16 December 2016), PubMed (1948 to December 2016), LILACS (Latin American and Caribbean Health Sciences Literature Database) (1982 to 16 December 2016), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com; last searched 17 June 2013), ClinicalTrials.gov (www.clinicaltrials.gov; searched December 2016), and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en; searched December 2016).

SELECTION CRITERIA

We included randomized controlled trials (RCTs) in which participants were undergoing phacoemulsification for uncomplicated cataract extraction. We included both trials in which topical NSAIDs were compared with topical corticosteroids and trials in which combination therapy (topical NSAIDs and corticosteroids) was compared with topical corticosteroids alone. The primary outcomes for this review were inflammation and best-corrected visual acuity (BCVA).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the full-text articles, extracted data from included trials, and assessed included trials for risk of bias according to Cochrane standards. The two review authors resolved any disagreements by discussion. We graded the certainty of the evidence using GRADE.

MAIN RESULTS

This review included 48 RCTs conducted in 17 different countries and two ongoing studies. Ten included studies had a trial registry record. Fifteen studies compared an NSAID with a corticosteroid alone, and 19 studies compared a combination of an NSAID plus a corticosteroid with a corticosteroid alone. Fourteen other studies had more than two study arms. Overall, we judged the studies to be at unclear risk of bias. NSAIDs alone versus corticosteroids aloneNone of the included studies reported postoperative intraocular inflammation in terms of cells and flare as a dichotomous variable. Inflammation was reported as a continuous variable in seven studies. There was moderate-certainty evidence of no difference in mean cell value in the participants receiving an NSAID compared with the participants receiving a corticosteroid (mean difference (MD) -0.60, 95% confidence interval (CI) -2.19 to 0.99), and there was low-certainty evidence that the mean flare value was lower in the group receiving NSAIDs (MD -13.74, 95% CI -21.45 to -6.04). Only one study reported on corneal edema at one week postoperatively and there was uncertainty as to whether the risk of edema was higher or lower in the group that received NSAIDs (risk ratio (RR) 0.77, 95% CI 0.26 to 2.29). No included studies reported BCVA as a dichotomous outcome and no study reported time to cessation of treatment. None of the included studies reported the proportion of eyes with cystoid macular edema (CME) at one week postoperatively. Based on four RCTs that reported CME at one month, we found low-certainty evidence that participants treated with an NSAID alone had a lower risk of developing CME compared with those treated with a corticosteroid alone (RR 0.26, 95% CI 0.17 to 0.41). No studies reported on other adverse events or economic outcomes. NSAIDs plus corticosteroids versus corticosteroids aloneNo study described intraocular inflammation in terms of cells and flare as a dichotomous variable and there was not enough continuous data for anterior chamber cell and flare to perform a meta-analysis. One study reported presence of corneal edema at various times. Postoperative treatment with neither a combination treatment with a NSAID plus corticosteroid or with corticosteroid alone was favored (RR 1.07, 95% CI 0.98 to 1.16). We judged this study to have high risk of reporting bias, and the certainty of the evidence was downgraded to moderate. No included study reported the proportion of participants with BCVA better than 20/40 at one week postoperatively or reported time to cessation of treatment. Only one included study reported on the presence of CME at one week after surgery and one study reported on CME at two weeks after surgery. After combining findings from these two studies, we estimated with low-certainty evidence that there was a lower risk of CME in the group that received NSAIDs plus corticosteroids (RR 0.17, 95% CI 0.03 to 0.97). Seven RCTs reported the proportion of participants with CME at one month postoperatively; however there was low-certainty evidence of a lower risk of CME in participants receiving an NSAID plus a corticosteroid compared with those receiving a corticosteroid alone (RR 0.50, 95% CI 0.23 to 1.06). The few adverse events reported were due to phacoemulsification rather than the eye drops.

AUTHORS' CONCLUSIONS

We found insufficient evidence from this review to inform practice for treatment of postoperative inflammation after uncomplicated phacoemulsification. Based on the RCTs included in this review, we could not conclude the equivalence or superiority of NSAIDs with or without corticosteroids versus corticosteroids alone. There may be some risk reduction of CME in the NSAID-alone group and the combination of NSAID plus corticosteroid group. Future RCTs on these interventions should standardize the type of medication used, dosing, and treatment regimen; data should be collected and presented using the Standardization of Uveitis Nomenclature (SUN) outcome measures so that dichotomous outcomes can be analyzed.

A novel hydrogel with dual temperature and pH responsiveness based on a nanostructured lipid carrier as an ophthalmic delivery system: enhanced trans-corneal permeability and bioavailability of nepafenac

A schematic illustration of a novel formulation that can be instilled on the surface of eyes (A) and the results of in vivo studies (B and C).

Comparative outcomes of femtosecond laser-assisted cataract surgery and manual phacoemusification: a six-month follow-up

BACKGROUND

To explore efficacy and safety outcomes in patients undergoing femtosecond laser-assisted cataract surgery (FLACS) versus manual phacoemulsification cataract surgery (PCS).

DESIGN

Prospective consecutive nonrandomized comparative cohort study.

PARTICIPANTS

A total of 124 eyes from 106 patients (70 in FLACS and 54 in PCS).

METHODS

Comparison of FLACS with PCS over 6 months.

MAIN OUTCOME MEASURES

Macular central subfield thickness (CST), cube volume (CV), cube average thickness (CAT), endothelial cell density (ECD), central corneal thickness (CCT) and photon count value (PCV).

RESULTS

CST, CV and CAT increased postoperatively, which did not return to preoperative levels by 6 months. The values were similar between groups throughout the follow-up, and comparison of changes from baseline also showed no significant difference. Preoperative ECD showed significant difference, which decreased postoperatively and remained stable during follow-up, being lowest at 1 month. FLACS had greater endothelial cell loss than PCS, which was not significant. CCT in both groups increased, reaching maximum on day one and tended to decrease thereafter. No significant differences were found regarding postoperative values and the mean increase. In both groups, mean PCV increased from preoperatively to day one, week one and month one. Flare values in FLACS were lower than PCS, reaching statistical significance at 6 months (P = 0.001). However, the differences in changes of PCV were not significantly different at any visit.

CONCLUSIONS

Both FLACS and PCS achieved similar safety and efficacy outcomes for performing cataract surgery. Flare values in eyes with FLACS were lower than those with PCS at 6 months postoperatively.

Supramolecular hydrogel of non-steroidal anti-inflammatory drugs: preparation, characterization and ocular biocompatibility

A supramolecular hydrogel based on a peptide (GFFY) and non-steroidal anti-inflammatory drugs (naproxen and ibuprofen) was synthesized for use as a topical gel.

Prevention of Cystoid Macular Edema After Cataract Surgery in Nondiabetic and Diabetic Patients: A Systematic Review and Meta-Analysis

PURPOSE

To evaluate the optimum medical strategy to prevent cystoid macular edema (CME) after cataract surgery.

DESIGN

Systematic review and meta-analysis.

METHODS

setting: Cochrane, MEDLINE, and EMBASE databases were searched to identify eligible randomized controlled trials (RCTs).

STUDY POPULATION

RCTs comparing medical strategies to prevent CME after uncomplicated cataract surgery in nondiabetic and diabetic patients.

OBSERVATION PROCEDURES

Data were extracted by 2 authors independently. Quality of individual RCTs was assessed using the Cochrane Collaboration's tool for assessing risk of bias and Delphi criteria.

MAIN OUTCOME MEASURES

Odds of developing CME within 3 months postoperatively and foveal thickness, macular volume and corrected distance visual acuity change within 3 months postoperatively, as compared to baseline.

RESULTS

Seventeen trials reported incidence rates. Topical nonsteroidal anti-inflammatory drugs (NSAIDs) significantly reduced the odds of developing CME as compared to topical corticosteroids in nondiabetic (odds ratio [OR] 0.11; 95% confidence interval [95% CI] 0.03-0.37) and mixed populations (OR 0.05; 95% CI 0.02-0.11). A combination of topical corticosteroids and NSAIDs significantly reduced the odds of developing CME as compared to topical corticosteroids in nondiabetic (OR 0.21; 95% CI 0.10-0.44) and diabetic patients (OR 0.17; 95% CI 0.05-0.50). Intravitreal corticosteroid or anti-vascular endothelial growth factor injections did not show any additional benefit in diabetic subjects.

CONCLUSIONS

Topical NSAIDs significantly reduced the odds of developing CME, as compared to topical corticosteroids, in nondiabetic and mixed populations. A combination of topical NSAIDs and corticosteroids reduced the odds of developing CME in nondiabetic and diabetic patients, as compared to topical corticosteroids.

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.

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.

Comparing the Efficacy of Ophthalmic NSAIDs in Common Indications

Objective: To review the commercially available ophthalmic nonsteroidal anti-inflammatory drugs (NSAIDs), identify opportunities for therapeutic substitutions within and outside of their Food and Drug Administration (FDA)-approved indications, and identify clinically superior drugs within the class for specific indications. Data Source: A PubMed search (1992 through January 2014) was performed on the terms diclofenac, ketorolac, flurbiprofen, bromfenac, and nepafenac. Study Selection and Data Extraction: Clinical trials, meta-analyses, and review articles were evaluated if they were written in English and pertained to human subjects. Studies were excluded if they were in vitro studies, solely evaluated pharmacokinetic or pharmacodynamic properties, did not relate to the topical ophthalmic route, did not evaluate the FDA-approved indications of any available ophthalmic NSAID, or compared a reviewed drug with a nonreviewed drug (without placebo comparison). Data Synthesis: A total of 67 articles met the criteria for evaluation. Article quality, study design, and dosing of the medications were assessed to determine the clinical applicability of the results. The quality of the article was determined using the Oxford Centre for Evidence-based Medicine Levels of Evidence 1. Conclusions: Many formulations of the 5 reviewed NSAIDs have been studied across the 4 primary indications. These indications are (1) pain and inflammation associated with cataract surgery, (2) pain associated with corneal refractive surgery, (3) inhibition of intraoperative miosis, and (4) seasonal allergic conjunctivitis. Several studies have directly compared drugs within this class and have identified instances in which certain selections are therapeutically superior or equivalent to another. This information provides practitioners with guidance in selecting an optimal medication.

Subconjunctival injection of XG-102, a JNK inhibitor peptide, in patients with intraocular inflammation: a safety and tolerability study

PURPOSE

We aimed to investigate the safety, tolerability, and systemic diffusion of a single escalating dose of XG-102 (a 31-D-amino-acid peptide inhibiting JNK pathway activation), administered subconjunctivally in the treatment of post-surgery or post-trauma intraocular inflammation.

METHODS

This is a dose-escalating, tolerance Phase Ib study. Twenty patients with post-surgery or post-traumatic intraocular inflammation were assigned to 1 of the 4 dose escalating (45, 90, 450, or 900 μg XG-102) groups of 5 patients each. Patients were evaluated at 24, 48 h, 8, and 28 days following the administration of XG-102, including laboratory tests, standard eye examinations, vital signs, and occurrence of adverse events. A single plasma quantification of XG-102 was performed 30 min after administration, according to previous pharmacokinetics studies performed on volunteers.

RESULTS

A total of 17 non-serious adverse events, considered unrelated to the study treatment, were reported for 10 patients. The adverse event incidence was not related to the drug dose. All patients experienced a decrease in intraocular inflammation as of 24 h post-administration and this decrease was sustained up to 28 days thereafter. No patient required local injection or systemic administration of corticoids following the administration of XG-102. XG-102 was undetectable in the first 3 dose groups. In the fourth-dose group (900 μg) the XG-102 plasma levels were above the limit of detection for 3 patients and above the limit of quantification for 1 patient.

CONCLUSIONS

In this first clinical trial using XG-102, administered as a single subconjunctival injection as adjunct therapy, in patients with recent post-surgery or post-trauma intraocular inflammation is safe and well tolerated. Further studies are required to evaluate its efficacy.

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.