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EW SHOW DAILY 40 Tuesday, May 10, 2016 Meeting Reporter Longer regimens of NSAIDs are needed postop, up to 90 days in high-risk patients, Dr. Holland said. A majority (52%) of ASCRS sur- vey respondents discontinue NSAID use at 4 weeks postop in average patients. "That's prudent, as well as the preop loading of the cornea," Dr. Holland said about the 90-day postop use in high-risk patients. Numerous NSAIDs are approved for U.S. sale as pain control medica- tions. "Pain causes the patient to have a question of the surgical experi- ence," Dr. Holland said. "Inflam- mation that leads to pain certainly increases complications." EW Editors' note: This event was support- ed by educational grants from Alcon (Fort Worth, Texas), Bausch + Lomb (Bridgewater, New Jersey), Imprimis Pharmaceuticals (San Diego), Ocular Therapeutix (Bedford, Massachusetts), and Omeros (Seattle). by Rich Daly EyeWorld Contributing Writer "Treated CME that even gets back to 20/20 vision is not the same as prevented CME," Dr. Holland said. "We certainly see patients who can see 20/20 on Snellen visual acuity who are not happy with their vision," Dr. Holland said. That danger makes it worth the effort to try to prevent CME, Dr. Kim said. Several NSAIDs have been found in published studies to effectively prevent CME, which ocular imaging has found to occur in up to 19% of healthy eyes postop. A 2014 study found that NSAIDs alone are more effective than corticosteroids alone in preventing CME after cataract surgery. A 2013 study found the combination of steroids and NSAIDs were more effective in preventing CME than steroids alone. Eighty-one percent of ophthal- mic surgeons think it is somewhat or very important to combine cortico- steroids and NSAIDs to treat postop inflammation, according to the 2015 ASCRS Clinical Survey. However, less than 15% use intraop anti-inflam- matories. cations, like trauma to the iris or posterior chamber rupture. Patients may be predisposed to increased postop inflammation if they have some comorbidities, such as corneal disease or glaucoma. A 2007 prospective case series of 1,500 cataract surgery patients found 8.4% experienced early onset postop inflammation. The authors concluded that early onset postop inflammation causes pain, decreased vision, and patient anxiety in the acute phase. An additional component of post-cataract CME is that even when it is identified and successfully treat- ed to produce good visual acuities, patients remain very dissatisfied. "Typically these patients aren't happy because their contrast sensi- tivity was worsened because of the disruption of the photoreceptors from that edema," Dr. Kim said. "So even though the edema resolved, the damage was permanent." Dr. Holland agreed that from his clinical experience it appears that the restored vision following CME is never as good as it was before onset. C hanging patient expec- tations—plus improved clinical knowledge—have underscored the impor- tance of pain and in- flammation control to obtain good cataract surgery outcomes. "Patients can have excellent vision, but if they have discomfort, they think something went wrong with the operation," said Edward Holland, MD, Cincinnati. The growing importance of any pain following cataract surgery is partially a function of the growing comfort of patients with cataract surgery, which is increasingly seen as a minor, routine surgery. So any postop discomfort takes on an out- sized role. "Postop pain and discomfort is a critical part of the surgery, as patients' expectations are higher than ever," Dr. Holland said during an EyeWorld CME Educational Symposium. Terry Kim, MD, Durham, North Carolina, noted that surgeons tend to not focus on patient pain when assessing outcomes. That pain con- tinuum can range from dry, watery, or red eyes all the way to moderate to severe pain. "That's an important thing that we need to pay attention to," Dr. Kim said. Dr. Kim cited a 2005 study of 306 patients that assessed pain and satisfaction immediately postop. Among the study population, 37% had mild or moderate postop pain, and any postop pain was the most significant predictor of dissatisfac- tion with their care. Research has placed growing emphasis on the importance of avoiding postop inflammation. Ob- taining optimal results from cataract surgery requires controlling and preventing inflammation. Dr. Kim noted that some cataract patients who have postop inflammation can face sight-threatening conditions, like cystoid macular edema (CME). Dr. Holland noted that surgery causes tissue damage that induces inflammation. Sources of postop inflammation can range from nor- mal damage through uncomplicated cataract surgery to surgical compli- Pain, discomfort control critical to cataract success Dr. Kim says that surgeons tend to not focus on patient pain when assessing outcomes in cataract surgery.

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