Routine NSAID use questioned based on multiple factors

Topical nonsteroidal anti-inflammatory drugs (NSAIDs) are often used off-label for multiple purposes in cataract surgery, but such treatment is often being administered with limited supporting evidence and carries a high cost along with potential risks, said Walter Stark, MD, at Spotlight on Cataracts 2007.

The only approved indications for topical NSAIDs in cataract surgery are to treat postoperative pain or inflammation. However, these agents are being prescribed off-label outside of those intended uses to potentiate mydriasis as well as to prevent or treat cystoid macular edema (CME).

A few studies have shown topical NSAIDs increase pupil size and decrease constriction. However, good data are lacking to show a benefit for CME prevention. When used in eyes with persistent CME, topical NSAID use has been shown to provide a good response measured by improvement in lines of vision. However, CME recurred within a few months after the medication was stopped in one study.

"At an average wholesale cost of about $79 dollars per bottle and up to $130 retail multiplied by 2.5 million cataract operations performed annually, topical NSAID use can add $250 million to the cost of care. In addition to the economic consequences, surgeons need also consider use of these agents might cause complications, including corneal melt," Dr. Stark said.

Dr. Stark told attendees he uses topical NSAIDs preoperatively, administering four doses beginning 1 hour prior to surgery when starting the dilating drops. However, in eyes predisposed to CME, prophylactic treatment is initiated 1 to 3 days preoperatively and continued for 2 to 3 weeks after surgery.