Take steps throughout surgical case to avoid postoperative ocular inflammation

Inflammation is associated with every surgical procedure.

In most surgical specialties, postoperative inflammation is considered an expected part of the healing process. The associated discomfort and swelling are treated with cold compresses and oral analgesic medications, but the surgical site inflammation itself is not treated. In ophthalmology, postsurgical inflammation is associated with undesirable discomfort, photophobia and reduced visual function, recently labeled as surgical temporary ocular discomfort syndrome (STODS) by a consensus panel of experts. In addition, unique to the eye, intraocular inflammation after surgery can result in corneal endothelial cell death, trabecular meshwork damage, peripheral anterior or posterior synechiae, IOL precipitates, posterior capsular fibrosis with opacity and visually significant cystoid macular edema (CME). For this reason, ophthalmic surgeons treat postoperative inflammation aggressively.

I have a special interest in the prevention and management of STODS and postoperative ocular inflammation. As a busy ophthalmic surgeon, clinical investigator, medical advisory board member and company consultant for 50 years, I participated in many clinical trials on the prevention and management of postoperative ocular discomfort and inflammation. Some of the findings have been published, but many have not. In the following paragraphs, I will share a few of my learnings.

The most useful therapeutic agents currently available for the treatment of ocular postsurgical discomfort and inflammation include topical lubricants, topical and injected steroids, and topical NSAIDs. Occasionally, topical cycloplegics or anti-VEGF intravitreal injections are indicated.

Some level of STODS is present after all ocular surgical procedures, including intravitreal injections. Most senior patients have at least mild dry eye before surgery, and all patients have surgery-induced dry eye after surgery. The use of a quality topical lubricant before and after surgery reduces STODS, improves biometry accuracy, and results in improved patient comfort and more rapid visual recovery. The use of a topical lubricant before and after surgery is routinely of benefit, underutilized and easy to add to one’s routine pre- and postoperative regimen.

An important vision-threatening postoperative complication after ophthalmic surgical procedures is clinically significant CME. The most common procedure a comprehensive ophthalmologist performs is cataract removal and IOL implantation, so I will focus my comments on CME after this procedure. A good paper published on this topic by Chu and colleagues reviewed 81,984 cataract surgeries performed in the United Kingdom. Data on U.S. surgery from the IRIS Registry are also available on the internet. Visually significant CME was observed in 0.8% (U.S.) and 1.17% (U.K.) of eyes after uncomplicated cataract surgery in a patient without special risk factors. The top five risk factors that increased CME risk were diabetes (10% to 20%, depending on diabetic retinopathy severity), preoperative uveitis (5% to 10%, depending on uveitis severity), epiretinal membrane (5.6%), retinal vein occlusion (4.47%) and posterior capsular rupture (2.61%). Eyes with these five risk factors and a few other rarer diagnoses such as retinitis pigmentosa deserve aggressive preoperative, intraoperative and postoperative therapy to reduce the risk for CME and treat it when present.

A few personal thoughts on the prophylaxis and therapy of CME. Both steroids and NSAIDs are effective in reducing the risk for CME and treating it when diagnosed. As a single agent, topical NSAIDs are superior to topical steroids. The two agents used in combination are better than either alone, so a combined topical steroid/NSAID regimen is preferred, especially in high-risk cases. Preoperative treatment for 2 to 3 days can help reduce the incidence of postoperative CME. Continuing treatment for 6 to 8 weeks after surgery rather than the routine 3 to 4 weeks is helpful in high-risk patients. Good evidence supports the use of a subconjunctival injection of triamcinolone at the completion of surgery in patients with diabetes and other high-risk factors to prevent and, when present, treat clinically significant CME. Omidria (Rayner), which contains phenylephrine and ketorolac, added to surgical balanced salt irrigating solution can reduce intraoperative miosis and postoperative discomfort. Intracameral injection of a steroid and NSAID along with antibiotic at the completion of surgery is used by many surgeons (Dex-Moxi-Ketor PF, Imprimis). Intravitreal injection of triamcinolone and occasionally an anti-VEGF can rescue patients unresponsive to topical steroids and NSAIDs along with subconjunctival/sub-Tenon’s triamcinolone. Fortunately, we now have non-preserved Triesence (triamcinolone acetonide injectable suspension, Harrow) labeled for ocular use available again.

Postsurgical inflammation in the eye, the associated STODS and secondary ocular complications are preventable in many cases and, when present, treatable in the majority of patients. Effective therapy includes preoperative, intraoperative and postoperative topical over-the-counter ocular lubricants and prescription pharmaceutical agents, especially steroids and NSAIDs.

• Reference:
• Chu CJ, et al. Ophthalmology. 2016;doi:10.1016/j.ophtha.2015.10.001.

• For more information:
• Richard L. Lindstrom, MD, can be reached at rllindstrom@mneye.com.

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Sources/Disclosures

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Source:
Expert Submission

Disclosures:
Lindstrom reports having disclosures for AbbVie, Bausch + Lomb, Harrow, Imprimis and Surface Ophthalmics.

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