Topical NSAIDs Reduce Post Cataract Inflammation, Photophobia Better Than Intracanalicular Insert

Following a cataract surgery approach that uses intraoperative intracameral phenylephrine/ketorolac (to maintain mydriasis and continuously suppression inflammation), significantly fewer patients develop cystoid macular edema (CME) or photophobia, or both, when their postoperative care includes a twice-daily nonsteroidal anti-inflammatory (NSAID) drop than an intracanalicular dexamethasone insert, according to data published in Journal of Cataract & Refractive Surgery.

At a single surgical center, an investigator reviewed deidentified records of cataract procedures for consecutive adult patients between August 2019 and March 2021. Eyes meeting criteria were separated into 2 groups. Surgeons administered intracameral phenylephrine/ketorolac and moxifloxacin intraoperatively for both groups. Group 1 included 482 eyes treated postoperatively with intracanalicular dexamethasone insert (0.4 mg). Group 2 had 519 eyes that received bromfenac (0.075%, BID) starting 2 days before the operation and continuing for 4-week after the procedure. 

After a 90-day follow-up, significantly fewer patients who received the NSAID treatments developed clinical CME (0.4%,) compared with patients who received the dexamethasone insert (3.9%, P <.001). The postoperative NSAID-treated eyes also had fewer reports of photophobia (1.9%, vs 4.8% for the insert group, P =.012). 

These differences persisted even when a Cochran Mantel Haenszel test controlled for variables of baseline, demographic, and operative factors (P <.05). Also, pain, and breakthrough iritis cases — recurrence of inflammatory cells and flare after noted resolution at a prior visit — were reduced in the NSAID-only group, but not significantly so.

The study also shows that, in the absence of intracameral phenylephrine/ketorolac, the “conventional wisdom of using both NSAIDs and steroids may still hold true and provide better control of postoperative inflammation even when using sustained drug delivery systems,” the investigator reports.

Regardless of whether a surgeon offers postoperative topical NSAIDs or corticosteroids, or a combination of both, the success of the topical approach depends upon patient compliance. The primary advantage of the dexamethasone intracanalicular insert is that it can significantly reduce both postoperative pain and inflammation while decreasing the burden of frequent dosing. However, those benefits were found comparing the insert to a placebo. With this study, researchers compared it to topical NSAIDs and report that the topical NSAIDs are more effective in controlling pain and inflammation after cataract surgery.

“Due to the extended-release profile of the dexamethasone intracanalicular insert, only 1 dose is required for the entire duration of treatment, thus decreasing the burden of dosing frequency associated with topical treatment,” the researcher reports. However,
“this study compared sustained release dexamethasone insert and topical NSAIDs and found topical NSAIDs to be more effective in controlling pain and inflammation after cataract surgery compared with the dexamethasone insert.” The report suggests “a need for more efficacious formulations of sustained drug delivery modes for the control of inflammation in the setting of cataract surgery.”

Exclusion criteria comprised procedures and conditions such as combined cataract surgery, high-risk CME, and traumatic cataract. Limitations of the study included its retrospective, single-center design, and no available data for CME severity or duration. Overall, Omidria plus an NSAIDs-only regimen was found to be significantly better to reduce incidence of inflammation, photophobia, and relatively better for pain following cataract surgery.