Topical Nonsteroidal Anti-Inflammatory Therapy in Ophthalmology

Abstract

Topically applied nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used in the management and prevention of ocular inflammation and cystoid macular edema related to cataract surgery and the maintenance of mydriasis during cataract surgery. Other common uses are the reduction of discomfort after refractive surgery or in allergic conjunctivitis. NSAIDs primarily act as cyclooxygenase inhibitors and thus reduce the formation of endogenous PGs. Today, several NSAIDs are commercially available: diclofenac, flurbiprofen, indomethacin, ketorolac and suprofen. At present the ophthalmologist has to make a decision between the use of topical corticosteroids, with their potential adverse effects, or of topical NSAIDs, with their possibly increased benefit, unknown effect on ocular pressure, wound healing and corneal tissue, higher costs and limited track record. However, the improvement of surgical techniques might support an increasing use of NSAIDs in the future. Preoperative anti-inflammatory treatment should be considered in eyes at a higher risk of developing severe postoperative inflammatory reactions. This decision has to be made carefully and has to be guided by the clinical circumstances, the spectrum of diagnosis and the individual benefit-risk ratio of each patient.

Comparison between two cyclooxygenase inhibitors in an experimental dry eye model in albino rabbits

“…In accord with our work are some reports investigating topical steroids (17), NSAIDS (2,17,18) and cyclosporine A (19) for management of KCS. However, steroids have multiple adverse effects including cataract and increased intraocular pressure (17).…”

Pathophysiology of Cyclooxygenase Inhibition in Animal Models

“…Topically applied ns-NSAIDs (e.g., diclofenac, flurbiprofen, ketorolac, suprofen, indomethacin) inhibit COX-1 and COX-2 and are used in the management of various ophthalmic conditions such as seasonal allergic conjunctivitis; photophobia and pain after corneal refractive surgery; postoperative inflammation after cataract surgery; postoperative topical analgesia; prevention and treatment of cystoid macular edema; and prophylaxis of surgical miosis (Frucht and Zauberman 1984;Gaynes and Fiscella 2002;Sakamoto et al 1995;Schalnus et al 2003;Takahashi et al 2003). In veterinary medicine, systemic ns-NSAIDs (e.g., carprofen and flunixin meglumine) are used to treat uveal conditions (Giuliano 2004).…”

Topical Ocular Delivery of NSAIDs

“…As a class, NSAIDs have proven to be a safe and effective alternative to corticosteroids in the topical management of ocular inflammations (5). Currently these drugs are used topically very widely in inhibition of intra-operative miosis, management of post-operative inflammation, treatment of seasonal allergic conjunctivitis, prevention and treatment of cystoid macular edema and in the control of pain after photo refractive keratectomy (6). NSAIDs have also been found to be useful in decreasing bacterial colonization of contact lenses and prevent bacterial adhesion to human corneal epithelial cells (7).…”

“…Reducing the pH of the formulation increases the unionized fraction of the drug which enhances permeation. Being acidic, NSAIDs are inherently irritant (6) and reducing the pH of formulation further increases their irritation potential, as well as decreasing their aqueous solubility. In addition, the anionic nature of NSAIDs lends to the formation of insoluble complexes with cationic quaternary ammonium preservatives, such as benzalkonium chloride (9,10).…”