Maximizing surgical outcomes with new target-specific therapy

Chicago-New tools are available in the ongoing effort to prevent infection and inflammation during eye surgery, suggested speakers at a Sunday breakfast symposium at the Hilton Chicago. New formulations of nonsteroidal anti-inflammatory agents (NSAIDs) and fourth-generation fluoroquinolones are two of the agents that can be used in prophylactic strategies. NSAIDs are increasingly being used before and after surgery to treat pain and inflammation. Michael B. Raizman, MD, Tufts University School of Medicine, Boston, explained their use in cataract procedures.

“I’ve been a strong advocate of the use of topical nonsteroidals around cataract surgery and more recently around refractive surgery. I think these drugs are underutilized,” Dr. Raizman said.

NSAIDs are beneficial because they are powerful inhibitors of prostaglandins, which are responsible for increased vascular permeability in inflammation, pupil constriction, and some of the pain that patients may experience. Dr. Raizman said he uses nonsteroidals before and after cataract surgery to reduce pain and discomfort, prevent postoperative cystoid macular edema, help maintain an enlarged pupil, and improve visual outcomes.

He added that while nonsteroidals can cause adverse effects such as burning or irritation, overall they are quite safe. For routine cases, he typically asks patients to take NSAIDs two to three days before surgery and four weeks afterward. For high-risk patients, dosing should start earlier and might need to be continued as long as 12 weeks postoperatively.

A new NSAID is available for cataract and refractive procedures, according to Stephen S. Lane, MD, University of Minnesota, St. Paul. The FDA approved nepafenac ophthalmic solution 0.1% (Nevanac, Alcon Laboratories), the amide analog of the NSAID amfenac, in August, and the prodrug is expected to trigger a tremendous resurgence in the use of NSAIDs, Dr. Lane said.

Because nepafenac has a unique prodrug structure, penetration is optimized and reaches the targeted area more readily than other NSAIDs, Dr. Lane said. This structure also minimizes toxicity.

In one of the studies conducted for the FDA review process, “we found that nepafenac was effective in the treatment of anterior segment inflammation and in the treatment of ocular pain and resulted in significant efficacy in the early as well as late postoperative period,” Dr. Lane said. “It exhibited tremendous anti-inflammatory efficacy regardless of the dosing schedule.”

A series of clinical trials has confirmed that the drug is very safe and well tolerated, he added.

Edward J. Holland, MD, University of Cincinnati, described how to evaluate prophylaxis to minimize infection, while Francis S. Mah, MD, University of Pittsburgh School of Medicine, reviewed the goals of antimicrobial prophylaxis for cataract and refractive surgery.

The program chairman and moderator was Carmen A. Puliafito, MD, Bascom Palmer Eye Institute, Miami. The program was jointly sponsored by Ophthalmology Times and the New York Eye and Ear Infirmary and supported by an unrestricted educational grant from Alcon Laboratories.