inflammation and success in refractive cataract surgery
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Supplement to EyeWorld July 2013
Inflammation and success inrefractive cataract surgeryNew anti-inflammatory therapeuticsThere are factors that we know have helpedimprove outcomes in patients who are re-ceiving advanced technology IOLs, saidTerry Kim, MD, professor of ophthalmol-ogy, Duke University School of Medicine,Durham, N.C. Among the more familiar factors are patient selection, improved biometry and keratometry, OCT imaging,and femtosecond laser technology.
One variable tends to be overlooked interms of how important it is to the out-comes of refractive cataract procedures: inflammation. The goal with these proce-dures, said Dr. Kim, should be to eliminatepost-cataract inflammation.
Accreditation StatementThis activity has been planned and imple-mented in accordance with the EssentialAreas and policies of the AccreditationCouncil for Continuing Medical Educationthrough the joint sponsorship of the Ameri-can Society of Cataract and Refractive Sur-gery (ASCRS) and EyeWorld. ASCRS isaccredited by the ACCME to provide contin-uing medical education for physicians.
Educational ObjectivesOphthalmologists who participate in thiscourse will: Identify the impact of ocular inflammationon outcomes in refractive cataract surgery;
A lot of us are not aware of some ofthe recent advances in therapeutic agents,said Dr. Kim. Weve had some new and ex-citing developments in terms of our choicesfor anti-inflammatory therapy with regardto both topical corticosteroids and non-steroidal agents, he said.
In terms of nonsteroidal anti-inflam-matory drugs (NSAIDs), there have beensome notable reformulations of familiaragents. Prolensa (bromfenac 0.07%), whichreceived FDA approval in April, provides alower concentration of the active ingredientthan Bromday (bromfenac 0.09%). The newdrug is approved for once-a-day daily dosing1 day preop, the day of surgery, and 14 dayspostoperatively.
David F. Chang, MD, has received a retainer, ad hoc fees, or other consulting income from: Abbott Medical Optics, Clarity Medical Systems, LensAR, and Transcend. He is a member of the speakersbureaus of:Allergan and Zeiss Certified. He has received researchfunding from Glaukos. Dr. Chang has investment interests in Calhourn Vision, ICON Bioscience, PowerVision, and Revital Vision. He receives a royalty or other financial gain from Eyemaginationsand SLACK Inc.
Uday Devgan, MD, has received a retainer, ad hoc fees, or otherconsulting income from: Aaren Scientific, Bausch & Lomb, GersonLehman Group, Hoya Vision Care, and ISTA. He is a member of thespeakers bureau for Alcon. Dr. Devgan has an investment interest inSpecialty Surgical and receives a royalty or other financial gain fromAccutome.
Terry Kim, MD, has received a retainer, ad hoc fees, or other consulting income from: Alcon, Bausch & Lomb, ISTA, Ocular Systems, Ocular Therapeutix, PowerVision, and SARCode Bioscience.
Dr. Kim joined a faculty of experts tolook at Knocking Down Inflammatory Barriers to Success in Refractive Cataract Surgery at an EyeWorld CME Educationsymposium held at the 2013 ASCRSASOASymposium & Congress. Their objectiveswere to recognize the impact of ocular inflammation on outcomes in refractivecataract surgery, understand the role of anti-inflammatory therapies in mediating andpreventing anterior and posterior segmentocular tissue response throughout the in-flammatory cascade, and identify strategiesto prevent edema and relieve pain by maxi-mizing the formulation of anti-inflamma-tory agents to enhance their penetrationinto target tissues.
This CME supplement is supported by an unrestrictededucational grant from Bausch + Lomb.
Understand the role of anti-inflammatorytherapies in mediating or preventing oculartissue response throughout the inflammatorycascade; and Identify strategies to prevent edema and relieve pain by maximizing the penetration vehicle of anti-inflammatory agents into targettissues.
Designation StatementThe American Society of Cataract and Refrac-tive Surgery designates this live educationalactivity for a maximum of 0.5 AMA PRA Cate-gory 1 Credits. Physicians should claim onlycredit commensurate with the extent of theirparticipation in the activity.
Financial Interest DisclosuresThe faculty have disclosed the following financial interest relationships within the last 12 months:
Francis S. Mah, MD, has received a retainer, ad hoc fees, or otherconsulting income from: Alcon, ForSight Labs, and ISTA. He is amember of the speakers bureau of Allergan and Bausch & Lomb.
Keith A. Warren, MD, has received a retainer, ad hoc fees, or otherconsulting income and is a member of the speakers bureau of:Alcon, Dutch Ophthalmic USA, and Genentech.
Staff member Laura Johnson has no financial interests to disclose.
Claiming CreditTo claim credit, participants must visitwww.CMESupplement.eyeworld.org to review educational content and downloadthe post-activity test and credit claim. Allparticipants must pass the post-activity testwith a score of 75% or higher to earn credit.Standard internet access is required. AdobeAcrobat Reader is needed to view the mate-rials. CME credit is valid through January30, 2014. CME credit will not be awardedafter that date.
Notice of Off-Label UsePresentationsThis activity may include presentations on
drugs or devices or uses of drugs or devicesthat may not have been approved by theFood and Drug Administration (FDA) or havebeen approved by the FDA for specific usesonly.
ADA/Special AccommodationsASCRS and EyeWorld fully comply with thelegal requirements of the Americans withDisabilities Act (ADA) and the rules and reg-ulations thereof. Any participant in this edu-cational program who requires specialaccommodations or services should contactLaura Johnson at firstname.lastname@example.org or703-591-2220.
The optimized pH represents an ad-vanced formulation designed to facilitatepenetration into the eye, said Dr. Kim,adding that it will be available as 1.6 mLand 3 mL in a 7.5-mL bottle.
Nepafenac, on the other hand, is nowavailable in a higher concentration of 0.3%,Ilevro. Originally available at a concentra-tion of 0.1% (Nevanac), the new formula-tion is also approved for once-a-day dosing1 day preop, on the day of surgery, and 2weeks postoperatively, and will be availableas 1.7 mL in a 4-mL bottle.
In terms of corticosteroids, Durezol (difluprednate emulsion 0.05%) is not new,having been launched in 2008. However,said Dr. Kim, The launch of difluprednaterepresented a new class of corticosteroidmedication that we had not seen in quite afew years. It is indicated for the treatment of inflammation and pain associated withocular surgery and anterior uveitis with QIDdosing.
More recently approved for the sameindications is Lotemax gel (loteprednol ophthalmic gel 0.5%), which uses a uniqueand innovative mucoadhesive technology toensure adherence to the ocular surface andenhance penetration into the eye.
Impact of inflammation on the posterior segment and the role of anti-inflammatory therapyAs a retinal surgeon dealing with patientswho have posterior segment disease, manytimes Im the person thats bringing a gunto a knife fight, said Keith A. Warren, MD,professor of ophthalmology, University of Kansas, and founder, Warren Retina Associates, Overland Park, Kan. For these patients, you really dont want any inflam-mation so it becomes very important to tryto stem that.
Dr. Warren offered a retina specialistsperspective on the effects of inflammationduring refractive cataract surgery, highlight-ing its impact on the posterior segment andthe role of anti-inflammatory therapy.
Dr. Warren believes that patients un-dergoing refractive cataract surgery havelittle or no tolerance for any intraocular inflammation. Advanced technology IOLs,such as multifocal IOLs in particular, dontwork if inflammation is present.
Basically, [patients] want to get theirmoneys worth, he said. Inflammatorycontrol in refractive cataract surgery pa-tients is tantamount to any successful out-come.
Common pathophysiologyMany retinal diseases share a common in-flammatory pathophysiology. In particular,surgeons performing refractive cataract sur-gery should remember that pseudophakiccystoid macular edema (CME) occurs bysimilar mechanisms.
During surgery, inflammation is causedby the release of cytokines and other signalsmeant to induce protection against insultsto the body. In the uveal tract, inflamma-tion thus occurs by a number of mecha-
nisms, but is ultimately characterized by abreakdown in the bloodretina barrier. Thisin turn leads to leakage of proteinaceousfluid, leading to swelling in the retina andin the ocular media.
This inflammation, with its resultingprostaglandin-mediated breach of thebloodretina barrier, puts any patient under-going refractive cataract surgery at high riskfor CME.
CME is a late onset complication, usually occurring 4-6 weeks after surgery.Studies have shown that increased retinalthickening occurs in a staggering 12% ofcases following uncomplicated cataract sur-gery,1 appearing 4-6 weeks after surgery.2
A full evaluation of each patient shouldbe conducted prior to surgery. This includesidentifying risk factors in the clinical historyby examining factors such as duration ofsystemic disease, length of surgery, compli-cations that may have occurred during sur-gery, and co-morbidities such as diabetes, aswell as conducting a thorough preop examto look for any signs of pre-existingretinopathy (Figure 1).
Dr. Warren also recommended perform-ing optical coherence tomography (OCT)during preop evaluation. The precise meas-urement of the retinal thickness provided byOCT allows surgeons to evaluate risk, helpsthem educate patients regarding their pre-and postop outcomes, and provides an ob-jective way to monitor res