Corneal Complications Following Corneal Complications Following Topical Nonsteroidal Anti-Topical Nonsteroidal Anti-inflammatory Drug Useinflammatory Drug Use

Martel, S., Akin M., Shih CY., Udell IJMartel, S., Akin M., Shih CY., Udell IJ

North Shore Long Island Jewish Health Systems North Shore Long Island Jewish Health Systems

April 2010April 2010

The authors have no financial interest in the subject The authors have no financial interest in the subject matter of this presentationmatter of this presentation

Purpose and BackgroundPurpose and Background

To examine the systemic and local risk factors To examine the systemic and local risk factors associated with corneal complications after topical Non-associated with corneal complications after topical Non-Steroidal Anti-Inflammatory Drug (NSAID) useSteroidal Anti-Inflammatory Drug (NSAID) use

To examine corneal complications after NSAID use in a To examine corneal complications after NSAID use in a cohort of patients presenting subsequent to the cohort of patients presenting subsequent to the removal of generic diclofenac from the marketremoval of generic diclofenac from the market

To our knowledge there is little data published To our knowledge there is little data published examining the systemic and local risk factors that may examining the systemic and local risk factors that may predispose patients to corneal complications after predispose patients to corneal complications after NSAID use NSAID use

MethodsMethods This was a retrospective review of all patients This was a retrospective review of all patients

referred to the North Shore-Long Island Jewish referred to the North Shore-Long Island Jewish Health Systems for corneal complications Health Systems for corneal complications following topical NSAID use from 1998-2009 following topical NSAID use from 1998-2009

All cases were reviewed; any questionable cases All cases were reviewed; any questionable cases where factors besides NSAIDs use could have where factors besides NSAIDs use could have contributed to complications were eliminated contributed to complications were eliminated

36 patients were included in the study36 patients were included in the study 23 of the 36 cases were subsequent to 23 of the 36 cases were subsequent to

the removal of diclofenac DSOS from the the removal of diclofenac DSOS from the marketmarket

ResultsResults

Mean age was 73Mean age was 73 The mean duration of topical NSAID use was The mean duration of topical NSAID use was

60 days (range 6-360 days) 60 days (range 6-360 days) 29/36 patients used NSAID drops for >2 29/36 patients used NSAID drops for >2

weeksweeks Average dosage used 4 times a day dosing Average dosage used 4 times a day dosing

(range 1-8 drops a day) (range 1-8 drops a day) Indications for NSAID use included post-Indications for NSAID use included post-

cataract surgery (79%) and dry eye (21%)cataract surgery (79%) and dry eye (21%)

Table 1: Types of NSAID usedNSAID Type Number of Patients

Nevanac ® 10

Acular ® 10

Xibrom ® 5

Diclofenac DSOS* 6

Voltaren ® 5

* Removed from the market 1999

Serologic Testing of Patients for Factors Predisposing Patients to

Corneal Melt Factors tested include: ANA, RF, SS-

A, SS-B, ESR 9 had positive blood work for

autoimmune factors, 6 negative. 21 patients still need to be tested

4/15 had known autoimmune disease, 5/15 reported no symptoms but had positive bloodwork

Bromfenac: Post-Phaco 6 Weeks Bromfenac: Post-Phaco 6 Weeks Patient had history of periorbital radiationPatient had history of periorbital radiation

2 wks after phacoemulsification Patient treated for persistent epithelial

defect using NSAID’s for 1 month

•The patient had no rheumatologic symptoms, but +RF, +ANA, & elevated ESR

Bilateral descemetocele after 7 days of Bilateral descemetocele after 7 days of QID Ketorolac preservative freeQID Ketorolac preservative free

62 y.o. patient with “Dry Eye” (+ RF and + 62 y.o. patient with “Dry Eye” (+ RF and + ANA)ANA)

ConclusionConclusion Corneal complications with NSAID use continue Corneal complications with NSAID use continue

to be seen despite the removal of generic to be seen despite the removal of generic diclofenac from the marketdiclofenac from the market

Risks factors include: graft vs host disease, Risks factors include: graft vs host disease, radiation, pseudophakic bullous keratopathy, dry radiation, pseudophakic bullous keratopathy, dry eye symptoms related to autoimmune processeseye symptoms related to autoimmune processes

Patients with Dry Eye Syndrome without Patients with Dry Eye Syndrome without clinically manifesting autoimmune disease may clinically manifesting autoimmune disease may be still be predisposed to corneal melts if they be still be predisposed to corneal melts if they have positive serologic markers (ANA, RF, SS-A, have positive serologic markers (ANA, RF, SS-A, SS-B)SS-B)

Patients with risk factors should be monitored Patients with risk factors should be monitored frequently to prevent corneal complications and frequently to prevent corneal complications and to allow prompt discontinuation of the drug if to allow prompt discontinuation of the drug if necessarynecessary