FACE OFF

NSAIDs for Vit-Ret Procedures

COORDINATED BY ABDHISH R. BHAVSAR, MD

Welcome to Face Off, a column that explores controversial topics in the diagnosis and management of retinal diseases. In this issue, we explore the use of nonsteroidal anti-inflammatory drugs (NSAIDs) for postoperative care of vitrectomy or scleral buckle cases. Any clinical information discussed in this context constitutes offlabel use. In addition, there has been no large-scale randomized clinical trial for postsurgical use of NSAIDs in retina surgery patients. Nonetheless, some retina specialists have added NSAIDs to their treatment regimen after retina surgery. Let us hear the debate.

ABDHISH R. BHAVSAR, MD

MIGUEL A. BUSQUETS, MD, FACS

In this new era of improved surgical technology, sutureless vitrectomy surgery, and decreased recovery time, many patients undergoing retinal surgery have developed an expectation and a mindset similar to cataract surgery patients. Retinal surgery patients often expect to have both excellent postoperative visual acuity and minimal to no discomfort within as short a time frame as possible, allowing them to resume their jobs and daily activities without significant interruption. By effectively reducing periocular, intraocular, and even intravitreal prostaglandin levels, NSAIDs such as ketorolac tromethamine 0.4% or 0.5% (Acular LS and Acular, Allergan), nepafenac 0.1% (Nevanac, Alcon), and bromfenac 0.09% (Xibrom, ISTA Pharmaceuticals) can be helpful in the post-vitrectomy or scleral buckling setting from both of these standpoints by minimizing postoperative inflammation and providing analgesia.¹

Because NSAIDs act via a different mechanism than corticosteroids to control inflammatory processes, these can be used in combination with steroid agents (such as prednisolone) to complement their effect, or by to avoid the potential side effects associated with steroid medications such as secondary glaucoma.

It should not be forgotten that cystoid macular edema (CME) can develop after retinal detachment surgery or vitrectomy surgery in general, particularly in patients with a history of uveitis. The advent of optical coherence tomography (OCT) has shown that these rates may be higher than once believed. NSAIDs can therefore be a valuable perioperative adjunct in these cases when CME is present, or when patients are at risk for it. For example, in patients undergoing macular surgery, particularly patients with premacular fibrosis and concomitant CME or diabetic patients who are at risk for macular swelling, a common protocol that is gaining favor is the use of intravitreal triamcinolone to assist in peeling the epiretinal and sometimes internal limiting membranes, then leaving the excess triamcinolone on the surface of the macula and treating the patient with an NSAID drop postoperatively. Similarly, patients undergoing scleral buckling procedures often show more rapid resolution of postoperative pain, which can be severe in some cases, when using an NSAID in combination with a steroid drop as part of the postoperative regimen.

GEOFFREY G. EMERSON, MD, PhD

Although injected and oral NSAIDs (eg, Toradol, acetaminophen) are excellent for controlling postoperative pain, I do not find much use for topical NSAIDs in the post-vitrectomy or post-scleral buckle period. My patients appreciate a simple regimen consisting of a vasodilating drop and a combination antibiotic/steroid drop. If additional drops are prescribed, I worry that compliance suffers.

Furthermore, the cost of topical NSAID (>$130 per 5 mL) is outrageous compared to prednisolone acetate 1% ($21 per 10 mL), and there are no convincing data that NSAIDs are better than steroids or have added benefit in this setting. Cystoid macular edema can occur after vitrectomy or scleral buckling, but a retrospective review by Kiss et al.¹ found it to be uncommon even after complex retinal detachment repairs. If fluorescein angiography or OCT shows macular edema after retinal surgery, the course of topical steroid can be extended rather than prescribing an NSAID drop that is expensive and probably not covered by insurance. RP