Commentary: Newer non-steroidal anti-inflammatory drugs for postoperative management in phacoemulsification. Are topical corticosteroids still obligatory?

Cataract extraction and intraocular lens implantation is the most commonly performed surgery worldwide. This procedure has revolutionized the management of preventable blindness in the developing world. Easier access to newer technology, manufacturing of foldable lens implants, and the “economies of scale” have made it possible to conduct millions of cataract surgeries that are affordable to large populations while also keeping the rate of complications or endophthalmitis within acceptable limits.

The “surgically-induced inflammatory response” is observed following an uneventful cataract extraction with lens implantation and is often incriminated in contributing toward the unwanted sequelae in the form of uveitis, pseudophakic macular edema (PMO), accelerated posterior capsular opacification, posterior synechia, or secondary glaucoma.[1] For a successful surgery and uncomplicated postoperative course, the said inflammatory response must be diligently managed. To achieve this, precise quantification of the inflammation in the form of anterior chamber flare measurement—subjectively by slit-lamp examination and objectively with a laser flare photometer—becomes imperative.[2]

Corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs) are crucial to our armamentarium in the postoperative management of pain and inflammation.[3] However, there has been a debate regarding which of these two is more effective and whether a single agent is equally effective (if yes, then which of the two) as compared to the combination therapy in controlling postoperative inflammation and prophylaxis of PMO. Traditionally, topical corticosteroids have been used after cataract surgery, and newer NSAIDs with better posterior segment penetration have found use in PMO, especially in the setting of high-risk cases, including diabetic retinopathy.[4]

Both classes of drugs are effective treatments individually; however, they also display synergy in therapeutic effect. While corticosteroids only find their indication postoperatively and their preoperative application has not shown additional prophylactic benefit, NSAIDs find preoperative, intraoperative, and postoperative application to achieve sustained pupillary dilatation during surgery, prophylaxis for PMO and postoperative pain, and containing surgically induced inflammation, respectively.[5]

Previously approved NSAIDs such as diclofenac fell out of favor following reports of corneal melt, although ketorolac continues to be used till today. Newer NSAIDs such as nepafenac and bromfenac are more popular with surgeons, especially the newer once-daily-use formulations such as nepafenac 0.3%. They are often started preoperatively and continued for 6–8 weeks in the postoperative period. Commonly used topical steroids available today include dexamethasone in solution or suspension, fluorometholone, prednisolone in solution or suspension, loteprednol, and difluprednate. Although topical steroids find wide usage in cataract surgery, the preference for a particular molecule varies with each surgeon or institution, including the frequency of application. The use of subconjunctival depot injection is falling out of favor in view of topical anesthesia and micro-incision wound construction techniques being employed in modern phacoemulsification.[6]

With the advent of the latest technology in phacoemulsification, such as anterior chamber stabilization, advanced ophthalmic viscosurgical devices (OVDs), and highly biocompatible IOL material, surgically induced inflammation has become minimal and the need for frequent use of topical steroids appears nonmandatory. The tissues manipulated or directly breached during an uneventful phacoemulsification, with a well-dilated pupil, are cornea and lens capsule only, both of which are avascular and incite minimal inflammatory response. Moreover, the use of corticosteroids is fraught with raised intraocular pressure, delayed wound healing, and lowered treatment compliance owing to frequent topical application. The latter often requires a caregiver to be present for proper application.

We feel that the use of corticosteroids could be reserved for high-risk situations, where either an intraoperative complication has occurred, such as injury or manipulation of iris, prolonged surgery in case of hard cataract, incomplete removal of OVDs, or loss of vitreous, or if a preexisting condition exists, such as diabetes, pseudo-exfoliation, or uveitis. In a routine, uneventful phacoemulsification without previously mentioned complications, NSAIDs alone may be adequate in postoperative management. More data is being published in support of this rising trend and in near future, topical steroids would probably find very limited use in routine phacoemulsification.[7]

Frequent topical medications are gradually seeing a declining trend with modern phacoemulsification. Many surgeons have rid their patients of the use of topical antibiotics and use intracameral moxifloxacin instead, at the end of surgery. Similarly, to achieve pupillary dilatation, a preservative-free combination of phenylephrine, lidocaine and tropicamide has been approved in India. Furthermore, once-daily dosing of NSAID appears to be nearly replacing topical steroids, particularly in steroid responders, as has been observed by the authors.[8] While it is interesting to observe this trend toward minimalism in order to improve patient compliance and reduce pharmacological side effects, it would also be interesting to study the effect of the combination of steroids and NSAIDs on the cornea in terms of endothelial cell loss and edema. Currently, the rationale of using or avoiding topical steroids substituted by once-daily dosing of NSAIDs in routine phacoemulsification will continue to be dictated by the existing practice patterns and individual surgeon preferences.