A Report by the American Academy of Ophthalmology Ophthalmic Technology Assessment Committee Retina/Vitreous Panel: Stephen J. Kim, MD,1 Scott D. Schoenberger, MD,2 Jennifer E. Thorne, MD, PhD,3 Justis P. Ehlers, MD,4 Steven Yeh, MD,5 Sophie J. Bakri, MD6
Ophthalmology, November 2015, Vol 122, 2159-2168 © 2015 by the American Academy of Ophthalmology. Click here for free access to the OTA.
Objective: To review the available evidence on the effectiveness of prophylactic topical nonsteroidal anti-inflammatory drugs (NSAIDs) in preventing vision loss from cystoid macular edema (CME) after cataract surgery.
Methods: Literature searches of the PubMed and the Cochrane Library databases were last conducted on January 21, 2015, with no date restrictions. The searches retrieved 149 unique citations. The first author reviewed the abstracts of these articles and selected 27 articles of possible clinical relevance for full-text review. Of these 27 articles, 12 were deemed relevant to analyze in full. Two additional articles were identified from the reference list of the selected articles, and another article was identified from a national meeting. The panel methodologist assigned ratings of level of evidence to each of the selected citations.
Results: Nonsteroidal anti-inflammatory drug therapy was effective in reducing CME detected by angiography or optical coherence tomography (OCT) and may increase the speed of visual recovery after surgery when directly compared with placebo or topical corticosteroid formulations with limited intraocular penetration. However, the use of NSAIDs did not alter long-term (≥3 months) visual outcomes. Furthermore, there was no evidence that the benefits observed with NSAID therapy could not be obtained similarly with equivalent dosing of a corticosteroid. The reported impression that there is a pharmacologic drug synergy from the use of both an NSAID and a corticosteroid is not supported by the literature. There is no uniform method of reporting CME in the literature, which prevents accurate assessment of its incidence and response to anti-inflammatory therapies.
Conclusions: Cystoid macular edema after cataract surgery has a tendency to resolve spontaneously. There is a lack of level I evidence that supports the long-term benefit of NSAID therapy to prevent vision loss from CME at 3 months or more after cataract surgery. Although dosing of NSAIDs before surgery may hasten the speed of visual recovery in the first several weeks after cataract surgery, there is no evidence that this practice affects long-term visual outcomes. Standardized reporting of CME based on OCT may allow for more uniform quantitation of its incidence and more reliable assessment of treatment outcomes.
1Department of Ophthalmology, Vanderbilt University School of Medicine, Nashville, Tennessee
2Retina Physicians & Surgeons, Inc., Dayton, Ohio
3Division of Ocular Immunology, Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
4Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
5Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
6Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota