New therapies and tools for surgical success

Chicago-Patients today have high expectations for cataract and refractive surgery, and experts at a breakfast CME symposium shared some of the techniques, agents, and strategies used to meet these expectations. The program was held at the Hyatt Regency McCormick Place.

New applications are appearing for nonsteroidal anti-inflammatory drugs  (NSAIDs) in cataract and refractive surgery, said Francis S. Mah, MD, assistant professor of ophthalmology, University of Pittsburgh School of Medicine. As patient and physician expectations have increased, a role has become apparent for NSAIDs preoperatively and postoperatively to reduce inflammation, pain, cystoid macular edema, and miosis, he added.

“Although steroids are very powerful anti-inflammatory agents, NSAIDs have been shown to have properties which can enhance and improve surgical outcomes,” Dr. Mah said.

Until recently, the widely used NSAIDs required q.i.d. dosing, which affected compliance and outcomes. However, a recently approved drug is given only twice a day making it more convenient for patients, Dr. Mah said. Bromfenac sodium ophthalmic solution 0.09% (Xibrom, ISTA Pharmaceuticals) has been widely used in Japan for 5 years and received FDA approval in March of this year. Bromfenac sodium is indicated for the treatment of postoperative inflammation in patients who have undergone cataract extraction.

U.S. studies of bromfenac sodium indicate that it is safe and well tolerated, said Eric D. Donnenfeld, MD, founding partner of Ophthalmic Consultants of Long Island, who participated in those trials.

“Of all the NSAIDs that I have tried, this one is the best tolerated with the least stinging,” he said. He added that the agent has an early onset and works rapidly.

Liver toxicity has also been investigated, since an oral formulation of the compound given at a significantly higher dose was withdrawn from the U.S. market because of such concerns. No systemic side effects were reported.

Y. Ralph Chu, MD, medical director of the Chu Vision Institute, Edina, MN, observed that pretreatment with NSAIDs is an off-label use but nonetheless is important. One recent study showed that outcomes were significantly better in patients who began taking an NSAID 3 days before surgery, compared with those who began the drug 1 day or 1 hour in advance or who received placebo.

John D. Hunkeler, MD, founder of the Hunkeler Eye Institute, Kansas City, MO, stressed the importance of meeting patient expectations.

“We have left the era of anatomical success and are in the era of functional success as a measure of surgical outcome,” he said.

“Patients demand painless, quick surgery with immediate recovery of vision and full visual function, and we need our pharmacologic aids to assist us in this,” he added.

A variety of agents are available as adjuncts to a good surgical outcome, including fourth-generation fluoroquinolones, topical steroids, lidocaine gel, hyaluronidase, and NSAIDs.

The program was jointly sponsored by Ophthalmology Times and the New York Eye and Ear Infirmary and supported by an unrestricted educational grant from ISTA Pharmaceuticals.