NSAIDs vs. Inflammation
BY LEO SEMES, OD, FAAO
Many over-the-counter medications are excellent short-term mediators of pain and inflammation, but I'm going to discuss the use of topical nonsteroidal anti-inflammatory drugs (NSAIDs) to treat surface and deep inflammation in eye care.
Topical NSAIDS have a variety of applications. Cataract surgeons have added Acular (ketorolac tromethamine ophthalmic solution 0.5%, Allergan) to their post-op regimens and the drug, now available in preservative-free and lower-strength formulations, also has an application in treating pseudophakic cystoid macular edema (CME). When CME following cataract surgery was a more prevalent complication, eyecare professionals found that the oral NSAID indomethacin successfully reduced the incidence of CME.
CME as a post-op complication resurfaced with the introduction of topical prostaglandins for IOP control. Experts developed several strategies based on some good evidence to skirt the issue of IOP control with a prostaglandin immediately before and after cataract surgery. Among them was concurrent treatment with steroids and/or topical NSAIDs.
At the European Society of Cataract and Refractive Surgeons meeting in September 2002, the Binkhorst lecture (Miyake et al, 2003) addressed post-op pseudophakic intraocular inflammation (anterior and posterior). The cause of CME appears related to the preservative in topical IOP-lowering medications rather than to the active ingredients. What is the evidence?
Looking at the Results
Topical diclofenac (Voltaren, Novartis; Cataflam, Novartis) controlled post-op anterior-segment inflammation better than did topical fluorometholone (eFlone, Novartis; FML, Allergan). Investigators extended this experiment to observations made on patients taking either latanoprost (Xalatan, Pfizer) or a vehicle who were administered either diclofenac or fluorometholone for anterior segment inflammation.
On the first post-op day, inflammation was about equal. Investigators noticed lower levels and shorter durations of inflammation in patients administered diclofenac than in those administered fluorometholone regardless of whether they were taking latanoprost or the placebo.
A second data set demonstrated a similar prevalence and severity of post-op pseudophakic CME for the same groups of patients. Together, these results suggest that inflammation is controllable with topical diclofenac and that latanoprost may not be the culprit.
A Closer Look at Timolol
In a Sherlock-Holmes approach for six groups of patients taking either preserved or non-preserved timolol or preserved or non-preserved vehicle, researchers measured inflammation in those treated with either diclofenac or fluorometholone. The greatest degree and duration of anterior segment inflammation occurred among those taking the preserved solutions and treated with fluorometholone. Also, CME was least prevalent among those in the "non-preserved" groups.
Combining the results of these studies, it appears that breakdown of the blood-ocular barrier is exacerbated more by the preservative common to both timolol and latanoprost (BAK), than by either of the active ingredients. Further, the results offer good evidence for using topical NSAIDs in the post-op period for pseudophakic patients.
Expanding the Use of NSAIDs
Undoubtedly, we'll see others using topical NSAIDs to treat ocular inflammation. And remember: Topical Acular won't reduce healing time when applied to the ocular surface of patients treated for corneal abrasion.
Dr. Semes is an associate professor at the University of Alabama at Birmingham School of Optometry.