New research published in the American Journal of Ophthalmology assessed the safety and efficacy of non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroid combination for postoperative management following cataract surgery.
Let’s start with some background.
While the standard form of cataract treatment (phacoemulsification) has decreased postoperative complications in patients, according to investigators, the occurrence of such incidences is still prevalent, including:
- Transiently impaired visual acuity (VA)
- Increased intraocular pressure (IOP)
- Cystoid macular edema (CME)
Management of these complications typically includes the use of topical antibiotics and anti-inflammatory drugs, including NSAIDs, corticosteroids, or a combination of both—though the best dose regimen has long been debated.
And the goal of this research.
Investigators conducted a meta-analysis to compare the safety and efficacy of these two anti-inflammatory treatments—both individually and together—for the postop management of cataract surgery.
Tell me about it.
A comprehensive search using the PRISMA system sought studies describing corticosteroids and NSAIDs in patients with age-related cataract surgery was conducted across several databases:
- Cochrane
- Embase
- PubMed
- Scopus
- Web of Science
- CiNAHL
Of note, PRISMA stands for “Preferred Reporting Items for Systematic Reviews and Meta-Analyses”.
The review was registered in PROSPERO, which is an international database of prospectively registered systematic reviews in health and social care, welfare, public health, education, crime, justice, and international development, where there is a health-related outcome.
And the inclusion criteria?
Studies identified in this search must have reported at least one of the following outcomes:
- Best-corrected visual acuity (BCVA)
- Reported in LogMAR
- Anterior chamber inflammation (ACI)
- Measured as flare
- Central macular thickness (CMT)
- Measured via optical coherence tomography (OCT)
- CME
- Identified via fluorescein angiography (FA) and/or OCT
Additionally, IOP values were measured via Goldmann tonometry and the number of postoperative complication events were noted.
So how many studies were identified?
Out of an initial 1,663 studies narrowed down to 124, exclusion and inclusion criteria identified 19 studies (all randomized controlled trials [RCTs]) with a cumulative total of 3,374 patients (3,638 eyes). Broken down:
- 4 multicenter RCTs
- 15 single-center RCTs
Mean age of patients ranged from 58.7 to 78.8 years, with 51.48% female.
How many received each treatment?
- Corticosteroids: 1,307 patients (1,368 eyes)
- NSAIDs: 1,479 patients (1,546 eyes)
- Combo: 687 patients (724 eyes)
Findings?
BCVA was comparable between the individual corticosteroid and NSAID groups. At 4 to 6 weeks, however, BCVA values were more favorable with the combination therapy group than corticosteroids (MD=-0.01 logMAR, 95% Confidence Interval [CI]: -0.02, -0.01, I2=0%).
For ACI, both individual groups had comparable flare values at Day 1 and Day 3, but were more favorable at Day 7, 14, and 4 to 6 weeks for the NSAID group:
- Day 7: MD= -9.17 photons/ms, 95% CI: -16.52, -1.82, I2=94%
- Day 14: MD= -5.23 photons/ms, 95% CI: -8.35, -2.11, I2=94%
- Weeks 4-6: MD= -1.62 photons/ms, 95% CI: -3.03, -0.20, I2=93%
How about for CMT/CME?
Evaluated at 4 to 8 weeks postoperatively, CME was more favorable in the NSAIDs groups than the corticosteroid groups (OR=0.16, 95% CI: 0.07, 0.35, I2=61%).
Further, fewer CME events were noted in the combination group compared to the corticosteroid group (OR=0.21, 95% CI: 0.10, 0.45, I2=31%).
For CMT—measured at 4 to 8 weeks—more favorable outcomes were noted among the NSAIDs groups vs the corticosteroids (MD= -13.26 micrometers, 95% CI: -18.66, -7.86, I2=81%).
And the combination groups experienced comparable CMT compared to corticosteroids (MD=-12.43 micrometers, 95% CI: -28.71, 3.84, I2=96%).
What about IOP and complications?
A comparable rate of complications was noted among the NSAIDs and corticosteroids groups in five studies.
Similarly, IOP was comparable between these same groups at Day 1, 7, and 4 to 6 weeks, as well as between combination and corticosteroids groups at 4 weeks.
And in a nutshell?
NSAIDs were more effective in decreasing CME, CMT, and ACI, while combination therapies were better at improving BCVA and CME.
Any limitations?
A few …. the study authors noted that each of the 19 studies had varying time points, treatment days, and amount of medication used, potentially affecting the analysis outcomes.
Other limitations included patients who had surgery on both eyes as well as the use of different NSAIDs and corticosteroids with varying concentrations.
See here for the complete list.
Expert opinion?
Per the authors, these findings indicate that NSAIDs alone and a combination therapy of NSAIDs with corticosteroids were individually more effective in managing postoperative inflammation vs corticosteroids alone.
In regards to this combination therapy, they stated that, “adding NSAIDs to the treatment is clearly superior to corticosteroids alone,” and that, “a synergistic effect is also suggested in combining both drugs.”
I’m sensing a “but” …
Yup. The cost differences between the two therapies was also noted: “Corticosteroids are more affordable than NSAIDs,” they wrote.
The authors recommended further cost-effectiveness research to better understand and guide current practice patterns.