Comment on: Comparative study of topical steroids vs nonsteroidal anti-inflammatory drugs to control postcataract surgery inflammation.

Abstract

We read with interest the study by Deka.1 Despite advances in our techniques and understanding of cataract surgery, postoperative inflammation remains a cause of discomfort and prolonged recovery and can affect visual acuity. This well-conducted prospective, randomized, investigator-masked controlled study compared 3 arms of postphacoemulsification cataract extraction medication regimens. The first arm (Group 1) received topical nonsteroidal anti-inflammatory drug (NSAID) for 3 days before cataract surgery and then for 1 month postoperatively, the second arm (Group 2) received no preoperative treatment and topical corticosteroid for 1 month postoperatively, and the third arm (Group 3) received topical NSAID for 3 days preoperatively and 1 month postoperatively in combination with topical corticosteroid for 14 days postoperatively. We commend the authors for their efforts but would like to comment on their study design and conclusions. Group 2, the arm receiving topical corticosteroid only, did not have any preoperative antiinflammatory treatment in stark contrast with the other 2 arms that were treated with 3 days of bromfenac 0.09% before cataract surgery. There is well-established evidence that preoperative use of antiinflammatory medication for 3 days before cataract surgery significantly reduces postoperative inflammation and cystoid macular edema (CME) and improves short-term visual recovery compared with no preoperative treatment.2 Presumably, if Group 2 also received 3 days of preoperative corticosteroid treatment, their modest and clinically insignificant increase in macular thickening observed at postoperative day 21 would have been entirely prevented. Furthermore, despite the absence of preoperative treatment, Group 2 still exhibited significantly less anterior chamber inflammation at days 1 and 7 postoperatively compared with Group 1 (NSAID only), which supports the more potent antiinflammatory properties of prednisolone acetate 1% compared with those of bromfenac 0.09%. CME is the most common cause of vision loss after cataract surgery and, therefore, understandably one of the primary focuses of this interventional trial. Despite its importance, there is no universally accepted definition of clinically significant postcataract CME, but a recent publication by the American Academy of Ophthalmology suggested a cutoff of 30% increase of central subfield thickness on optical coherence tomography from baseline as a reasonably sensitive and specific definition of clinically significant CME.3 Application of such a definition to results presented in Table 7, would likely result in no statistically significant differences among all 3 groups in incidence of CME. We applaud the authors for this well-performed prospective study and believe that it supports 2 previous assertions in the literature that preoperative use of anti-inflammatory medications for 3 days accelerates recovery of eyes after cataract surgery (but does not affect long-term visual outcomes) and that topical use of prednisolone acetate 1% alone without concomitant NSAID results in equivalent long-term visual acuity outcomes compared with combination therapy.2–4