COMMENTARY

Out With the Old, in With the New: The Best of AAO 2013

American Academy of Ophthalmology 2013

Roger F. Steinert, MD; Eric D. Donnenfeld, MD; Richard A. Lewis, MD

Disclosures

November 25, 2013

In This Article

Raising Quality With Nonsteroidals

Dr. Steinert: Let's turn to therapeutics and start with cataracts and some of the newer nonsteroidals. Eric?

Dr. Donnenfeld: Nonsteroidals have become the lynchpin of quality outcomes in cataract surgery. The biggest change in cataract surgery outcomes in the last 10 years may not be femtosecond lasers. It may be the universal adoption of nonsteroidals for cataract surgery, which have significantly reduced inflammation and provided better outcomes with less cystoid macular edema (CME), which is the reason that we use them.

The nonsteroidals have had some compliance issues. We have seen some toxicity issues with some of the earlier-generation nonsteroidals. Two new nonsteroidals have entered the market this year: bromfenac (Prolensa™) and nepafenac (Ilevro®). Both are unique in that they are once-daily nonsteroidals that provide excellent bioavailability and penetration to the posterior segment, are shown to prevent inflammation, reduce CME, and are extremely kind to the ocular surface. They have increased efficacy while reducing frequency. This is a major step for cataract surgeons, to be able to use these nonsteroidals to improve outcomes.

Dr. Steinert: The extra concentration and strength are not stressing the epithelium, as far as you can tell?

Dr. Donnenfeld: No. They seem to be very well tolerated. Nepafenac has added a vehicle that soothes the ocular surface. They have increased the bioavailability of bromfenac and actually decreased the concentration. So they have gone in different directions to solve the problem of toxicity. These nonsteroidals are extremely well tolerated, much better than the previous-generation nonsteroidals.

Dr. Lewis: Are you starting the patient on these drugs before surgery and then continuing for 2-4 weeks afterwards? What is your regimen?

Dr. Donnenfeld: Nonsteroidals are approved by the US Food and Drug Administration to be used after surgery. But it has been clearly shown that they need to be used before surgery. There is some debate about when they should be started. I start my patients on nonsteroidals 3 days before surgery. As long as you start at least the day before surgery, you are doing a good job for your patients.

You continue them -- the old way used to be 2 weeks – but 4 weeks is the optimal time because CME really peaks at about 4 weeks. So we are using our nonsteroidals 3 days preoperatively and then continuing them for 1 month postoperatively.

Expanding Nonsteroidal Applications

Dr. Steinert: Do you think that the nonsteroidals have invaded the glaucoma surgical space as much as they have in cataract, or is it cataract-driven?

Dr. Lewis: They have not had as much effect. The CME issue isn't quite as big a concern. From the standpoint of traditional glaucoma surgery, we are using mitomycin (an antifibrotic agent) to prevent scarring. It isn't as big a concern. On the other hand, we tend to use steroids more intensively and longer for our conventional surgeries. So we are going to the more potent steroids, such as difluprednate (Durezol®), to make sure that we are getting great anti-inflammatory control. With some of the old nonsteroidals, the discomfort they cause makes them a mixed blessing. Some of that has been alleviated with the new agents. Perhaps it should be relooked at.

Dr. Steinert: I have begun to wonder -- and maybe we should even do some trials on this -- about using nonsteroidals more with corneal transplant surgery. Currently, I avoid them because of the surface toxicity, which tends to be much more obvious in the postkeratoplasty patient early postoperatively, at least in my experience. I have seen some awful epitheliopathy.

The newer agents might not create that, even though they are not antirejection drugs, because the T cells cause rejection. A quieter overall environment might be less likely to have T cells surface, so maybe that would be an adjunct to steroid in corneal transplantation. Have you thought about that?

Dr. Donnenfeld: This year for the first time, we are doing more Descemet stripping endothelial keratoplasty (DSEK) lamellar surgery than penetrating [keratoplasty] surgery in the operating room. When we do most of our DSEKs, very commonly we are doing cataract surgery at the same time.

I agree completely -- in the past, we avoided the use of nonsteroidals because of toxicity issues. Now that we have an intact cornea, and corneal sensation is not jeopardized, it is the standard in my practice to use nonsteroidals with DSEK because you don't have any toxicity issues with the cornea that you have with the anesthetic cornea of a penetrating keratoplasty.

Now, with penetrating keratoplasty, the jury is out. I am going to side on not using nonsteroidals right now because of the anesthetic effect of nonsteroidals. My primary concern with transplants is healing.

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