Managing ocular inflammation

During the World Ophthalmology Congress this year held in Abu Dhabi, United Arab Emirates, Bausch + Lomb sponsored a symposium discussing the management of ocular inflammation. In this lecture Professors Uwe Pleyer, Emrullah Tasindi and Piergiorgio Neri looked at the challenges practitioners face within this field.

Is it still necessary to treat post-op inflammation?

Looking at the evolution of cataract surgery since 1998 Prof. Tasindi explained that today there are smaller incisions, it takes less time to perform surgery and premium lenses and new medications are available, which lead to less trauma and better surgical outcomes. However, this has also led to a rise in patient expectations.

"We have very good techniques now that minimize damage to the ocular surface, so everything is perfect and patients expect wonderful results with no complications," Prof. Tasindi continued. "But we always have complications in surgery. Endophthalmitis is one such complication and fortunately it is rare."

In looking at what is responsible for eye discomfort and inflammation he explained that post-surgical inflammatory medications are very important and the ocular effects of prostaglandins should be taken into consideration.

It was revealed at the ESCRS last year that the use of topical antibiotics prior to surgery is also very important, administering povidone-iodine prior to surgery in the conjunctiva demonstrated a lower rate of incidence of endophthalmitis. Additionally, applying cefuroxime 0.1 mL intracannular during surgery demonstrated a drop in the incidence of endopthalmitis. So, Prof. Tasindi exmplained that antiobiotics are now being used to try and stop endophthalmitis.

"Today we have topical anti-inflammatory agents in cataract surgery: corticosteroids and NSAIDs," he said. These work by blocking the inflammation and inhibiting the prostaglandins. "The effects of prostaglandins and the use of NSAIDs during ophthalmic surgery in my view is very important. Because prostaglandins are really responsible for initiating and maintaining ocular inflammation. It affects IOP, increases blood-aqueous barrier permeability and might even contribute to cystoid macular oedema (CME)," Prof. Tasindi added. However, both steroids and NSAIDs pose risks particularly for those patients that may be difficult cases and could need long-term treatment.

A new NSAID, Bromfenac, has shown some positive results versus a placebo treatment Prof. Tasindi noted. This new treatment has an enhanced cell membrane penetration ability and an increased duration of anti-inflammatory activity. In examining the intraocular tissue concentration after application of Bromfenac it was noted that accumulation in the cornea, cilliary and aqueous bodies was good. Within the retina and choroid the accumulation and concentration were high. "The single dose treatment measured in all tissues within the first 24 hours of the study," added Prof. Tasindi. "On the first day there was a high level of inflammation but by day 15 there was a vast difference between the placebo group and the Bromfenac group, which demonstrate a positive result for the use of NSAID drops in preventing inflammation."

In his practice, Prof. Tasindi revealed that he usually uses NSAIDs and topical antibiotics just prior to surgery, on the same day, then during surgery he would use intracameral cefuroxime and postoperatively he uses topical antibiotics and steroids up to 4 weeks after surgery. "The combination of steroids and NSAIDs in post-cataract surgery treatment can help to ensure the best results and patient satisfaction," he concluded.