By Lisa B. Arbisser, MD
This prospective double-masked study found that pre- and postoperative prophylactic topical ketorolac 0.5% andnepafenac 0.1% had no effect on post-cataract surgery macular volume in patients without risk factors. While the drugs were well tolerated, with minimal side effects and no negative effects on health-related quality-of-life (HRQOL), based on these results, the authors do not recommend prophylactic topical nonsteroidal anti-inflammatory drugs (NSAIDs) for patients undergoing routine phacoemulsification cataract extraction with no risk factors for macular edema and no intraoperative complications.
However, they continue to recommend prophylactic NSAIDs as an efficacious, safe intervention to minimize postoperative macular edema in at-risk patients (e.g., those with diabetes, retinal disease, complicated cataract surgery).
This is a practice-changing paper that contradicts the current thought that I have held since the publication years ago of a paper that found that using NSAIDs preoperatively and postop for one month reduced the risk of cystoid macular edema from 12 percent to 0 percent.
The current paper potentially could have a very important economic impact. I think ophthalmologists agree that patients at higher risk still deserve NSAIDs, but if the routine patient doesn't, then millions of dollars could be saved.
The study included 162 patients 18 years or older scheduled for routine phacoemulsification. They were randomized to placebo, ketorolac 0.5% or nepafenac 0.1% four times a day starting one day before surgery and continuing for four weeks after surgery. They underwent spectral-domain macular cube ocular coherence tomography scans measuring central subfield thickness (CST), macular cube volume and average macular cube thickness at baseline and one month postoperatively. HRQOL metrics were determined with the Comparison of Ophthalmic Medications for Tolerability (COMTOL) questionnaire.
Although intragroup differences showed that ketorolac and nepafenac were effective at minimizing increases in CST and there was an overall trend toward significance at one month after uneventful phacoemulsification cataract extraction, the differences were small and not significant when compared with placebo. Similarly, although ketorolac appeared to have greater efficacy than nepafenac at lowering total cube volume at one month, the difference with either medication compared with placebo was not significant.
COMTOL questionnaire results indicated no difference in tolerability, compliance, side-effect frequency, and effects on HRQOL between ketorolac and nepafenac compared with placebo.