The Role of Steroids and NSAIDs in Prevention and Treatment of Postsurgical Cystoid Macular Edema

Abstract

Background: Pseudophakic cystoid macular edema (PCME) remains one of the most common visionthreatening complication of phacoemulsification cataract surgery (PCS). Pharmacological therapy is the current mainstay of both prophylaxis, and treatment of PCME in patients undergoing PCS. We aimed to review pharmacological treatment options for PCME, which primarily include topical steroids, topical nonsteroidal antiinflammatory drugs (NSAIDS), periocular and intravitreal steroids, as well as anti-vascular endothelial growth factor therapy. Methods: The PubMed and Web Of Science web platforms were used to find relevant studies using the following keywords: cataract surgery, phacoemulsification, cystoid macular edema, and pseudophakic cystoid macular edema. Of articles retrieved by this method, all publications in English and abstracts of non-English publications were reviewed. Other studies were also considered as a potential source of information when referenced in relevant articles. The search revealed 193 publications. Finally 82 articles dated from 1974 to 2018 were assessed as significant and analyzed. Results: Based on the current literature, we found that corticosteroids remain the mainstay of PCME prophylaxis in uncomplicated cataract surgery, while it is still unclear if NSAID can offer additional benefits. In patients at risk for PCME development, periocular subconjunctival injection of triamcinolone acetonide may prevent PCME development. For PCME treatment the authors recommend a stepwise therapy: initial topical steroids and adjuvant NSAIDs, followed by additional posterior sub-Tenon or retrobulbar corticosteroids in moderate PCME, and intravitreal corticosteroids in recalcitrant PCME. Intravitreal anti-vascular endothelial growth factor agents may be considered in patients unresponsive to steroid therapy at risk of elevated intraocular pressure, and with comorbid macular disease. Conclusion: Therapy with topical corticosteroids and NSAIDs is the mainstay of PCME prophylaxis and treatment, however, periocular and intravitreal steroids should be considered in refractory cases.

Outcomes in diabetic macular edema switched directly or after a dexamethasone implant to a fluocinolone acetonide intravitreal implant following anti-VEGF treatment

“…These findings are consistent with the results from the FAME trials where a dip in mean BCVA was observed between months 9 and 18, followed by an improvement between months 18 and 24 following cataract surgery [11]. While cataract formation is undesirable, it is well known that steroid therapy that is still lasting at the time of cataract extraction helps to minimize inflammation and prevent pseudophakic cystoid macular edema (PCME): one of the most common vision-threatening complications of cataract surgery [31]. Recent reports suggest that FAc injection before cataract surgery may help to maintain stable macula, thus facilitating cataract surgery [32].…”

Anti-interleukin-6 receptor therapy with tocilizumab for refractory pseudophakic cystoid macular edema

“…In a comprehensive review of 82 publications from 1974 to 2018 on the role of steroids and NSAIDs in preventing and treating PCME, the authors concluded that while corticosteroids remained the mainstay for PCME therapy, the combination of topical steroids with adjuvant NSAIDs could prevent PCME in uncomplicated cataract surgery. 23 However, there is limited to no role for topical NSAID monotherapy in the treatment of inflammatory ME, 24 and no recent large studies have investigated NSAIDs as sole treatment for chronic CME. Because of the available scientific data, in conjunction with the fact that the etiology of our patient's macular edema may have had a uveitic component in addition to PCME, we chose not to pursue the NSAID treatment option for our patient.…”

Therapeutic Ophthalmic Lenses: A Review

“…Ocular injections (e.g., intravitreal, intracameral, subconjunctival, and sub-tenon injections) are considered an alternative route to increase the efficacy of drug delivery, in particular to the posterior segment of the eye. However, injections lead to an initial high peak of ocular drug concentration followed by rapid decay [ 18 , 19 ]. While the use of biodegradable drug-eluting intraocular implants could overcome this issue and sustain drug release for several months, any form of ocular injection or ocular implant remains invasive for the patient and it is associated to a higher risk of adverse events when compared to eye drops [ 20 ].…”