NSAIDs help control inflammation, prevent CME

With cataract and refractive procedures, ocular comfort and inflammation management are highly relevant to the patient's impression of a successful procedure. Add to that an expectation that an increase in visual acuity will follow closely on the heels of surgery, and the standards are set very high.

Therefore, a surgeon's focus should be on making sure to have all the tools needed to perform the most successful procedure possible, including the use of a pre- and postoperative nonsteroidal anti-inflammatory drug (NSAID) to eliminate inflammation, increase patient comfort, and minimize the risk of complications such as cystoid macular edema (CME).

Refractive procedures

The optimum dose for NSAIDs following LASIK would be 1 drop immediately following the procedure. The small linear epithelial defect around the edge of the flap is the only exposure of corneal nerves. This heals within 3 to 12 hours following LASIK and no additional NSAID is required.

I ask patients undergoing PRK to use ketorolac tromethamine 0.4% (Acular LS, Allergan) 4 times a day for the first 24 hours and then as needed for discomfort thereafter. Obviously, the epithelial defect in PRK and subsequent exposure of corneal nerves is much greater than what is observed with LASIK.

The focus of my use of NSAIDs in keratorefractive procedures is the control of pain and discomfort and not the control of inflammation. I always use a concomitant topical steroid after PRK because the use of an NSAID alone with a bandage contact lens can induce corneal infiltrates.

In contrast, the primary use of NSAIDs following cataract surgery is the control of intraocular inflammation by inhibiting the production of prostaglandins. Pain relief and enhanced pupillary dilation are additional reasons to use NSAIDs in association with cataract surgery, but the most important reason is for the control of inflammation and prevention of CME.

Because pain can be a major factor in surface ablation procedures like PRK, NSAIDs are a valuable tool in the effort to make the procedure more comfortable for the patient.

Francis W. Price Jr., MD, Indianapolis, and colleagues showed that ketorolac tromethamine 0.4% significantly reduced the incidence of severe or intolerable pain in the first 12 hours following PRK compared with vehicle, from 87.2% in the control group to 43% in the treatment group.¹ The median time to the first report of no pain in patients taking ketorolac tromethamine 0.4% was 24 hours, compared with 54 hours in patients receiving vehicle. At all time points in the first 48 hours postoperatively, patients who received vehicle were approximately twice as likely to require escape medication as those who received ketorolac tromethamine 0.4% (92.3% versus 46.8%, respectively).

Because they have a direct effect on the cyclooxygenase pathway, NSAIDs should be viewed as the primary agent for pain management at the time of surface ablation. In addition, NSAIDs do not have the potential disadvantages associated with steroid use, such as increased IOP and the potential for cataract formation when used as a long-term agent.

Cataract surgeries

An important intraoperative advantage of NSAIDs is the prevention of miosis during cataract surgery.^2-4 Smaller pupils make cataract surgery more challenging, with longer phacoemulsification times, more iris manipulation, and an increased risk of vitreous loss, all of which can contribute to significant postoperative complications.

As generally reported in the literature, the use of NSAIDs may increase pupil diameter by 0.75 to 1.25 mm. By increasing the size of the pupil from 6 to 7 mm, a 16% increase in diameter, the surgeon creates 36% more area in which to perform surgery; an increase from 7 to 8 mm, a 14% increase in diameter, yields 30% more area.

My regimen for the typical cataract patient is to use ketorolac tromethamine 0.4% four times daily for 2 days preoperatively, then four times in the hour before surgery when the patient also receives dilating drops. Postoperatively, the patient will take ketorolac tromethamine 0.4% and prednisolone acetate 1% (Pred Forte, Allergan) four times daily for 2 weeks, then taper to twice daily use for 2 to 4 weeks. For high-risk patients, such as those with diabetes, uveitis, vein occlusion, CME in the fellow eye, or epiretinal membranes, I increase the duration of preoperative ketorolac tromethamine 0.4% to 3 days and add a preoperative regimen of prednisolone acetate 1% for 3 days preoperatively.