We know it is important toaddress inflammation incataract surgery, particu-larly to prevent cystoidmacular edema (CME). In

a recent online survey of 36 surgeons,82.9% said they would lengthen the duration of anti-inflammatory therapypostoperatively in patients with knownrisk factors for inflammation, and 51.4%said they would use different anti-inflam-matory agents. When asked about the

acceptable level of inflammation onpostoperative day one, 45.7% said traceto 1+ was acceptable, and the same percentage (45.7%) said 1+ to 2+ was acceptable. Additionally, 85.7% said theirprimary reason for using non-steroidalanti-inflammatory drugs was to preventCME.

Although surgeons are split on theacceptable level of inflammation, I thinkeliminating clinically significant inflam-mation, especially in premium IOL cases,

is a better approach than trying to “catchup” and treat escalating inflammation.The goal for surgeons should be preven-tion of CME, not treating CME. Inflam-mation has a greater impact on patientsand on visual acuity than many surgeonsthink.

Dr. Holland is in practice at the Cincinnati Eye Institute. He can be contacted at eholland@holprovision.com.

Accreditation StatementThis activity has been planned and implemented in accordance with the Essential Areas and policies of theAccreditation Council for Continuing Medical Educationthrough the joint sponsorship of the American Society ofCataract and Refractive Surgery (ASCRS) and EyeWorld.ASCRS is accredited by the ACCME to provide continuing medical education for physicians.

Educational ObjectivesOphthalmologists who participate in this course will:• Identify conditions putting patients at higher risk for

inflammatory reaction after cataract surgery and theclinician impact of this reaction;

• Develop perioperative strategies to better addressocular inflammation.

Designation StatementThe American Society of Cataract and Refractive Surgery designates this live educational activity for amaximum of 0.5 AMA PRA Category 1 Credits.™ Physicians should claim only credit commensurate with the extent of their participation in the activity.

Claiming CreditTo claim credit, participants must visit www.CMESupplement.eyeworld.org to review expanded educational content and download the post-activity test and credit claim. All participants must passthe post-activity test with a score of 75% or higher toearn credit. Standard internet access is required.Adobe Acrobat Reader is needed to view the materials.

CME credit is valid through December 31, 2013. CME credit will not be awarded after that date.

Notice of Off-Label Use PresentationsThis activity may include presentations on drugs or devices or uses of drugs or devices that may not havebeen approved by the Food and Drug Administration(FDA) or have been approved by the FDA for specificuses only.

ADA/Special AccommodationsASCRS and EyeWorld fully comply with the legal requirements of the Americans with Disabilities Act(ADA) and the rules and regulations thereof. Any participant in this educational program who requires special accommodations or services shouldcontact Laura Johnson at ljohnson@ascrs.org or 703-591-2220.

Financial Interest DisclosuresThe faculty have disclosed the following financialinterest relationships within the last 12 months:

The impact of cataract surgery stress on ocularinflammation and refractive cataract outcomes

The true impact of inflammation

Introduction by Edward J. Holland, MD

Many systemic and ocularconditions can predisposepatients to inflammationand edema after cataractsurgery. However, it is not

always predictable. Ultimately, we areconcerned about three things: cystoidmacular edema (CME); corneal edema;and pain/discomfort.

CME is the most serious and sight-threatening type of inflammation, but itis also the most predictable.

The incidence of clinical CME isonly approximately 1% to 2% in moststudies; however, the incidence of angio-graphic CME is probably closer to 20% to30%. CME has an impact on postopera-tive vision, and the effect can be longterm or short term. It can also influencepatient satisfaction (Figure 1).

Case studyThe impact of corneal edema was high-lighted in a recent case of mine. A 77-year-old woman was referred to me byanother physician. She was hyperopicwith narrow angles and had laser periph-eral iridotomies in both eyes. She hadmoderate cataracts in both eyes, and herbest-corrected visual acuity was approxi-mately 20/60.

She underwent uncomplicated rou-tine cataract surgery in her left eye. Dueto her short anterior chamber depth, thephacoemulsification energy was probablycloser to the cornea than in a typical case.

On the day after surgery, she wasunhappy. She was experiencing the usualpostoperative symptom of foreign bodysensation, and she stated that her visionwas “like looking through glass.” In fact,

her vision was not great. It was 20/200,which improved to 20/60 pinhole vision.She had diffuse corneal edema with moreedema centrally.

One week after surgery, she was bet-ter (1+ corneal edema and folds) but stillhad foreign body sensation and was nothappy with her vision.

At this time, her vision was 20/80,and her cornea had persistent edema. Ittook approximately two months for hercornea to clear, and she was not happywith the long, drawn-out postoperativecourse.

This case shows that even in stan-dard uncomplicated surgery, some eyeswill become very inflamed. This inflam-mation can delay visual recovery, whichmay delay the ability to return to normalactivities.

by Bonnie An Henderson, MD

This CME supplement is supportedby an unrestricted educational grantfrom Alcon Laboratories.

Figure 1. Inflammation after cataract surgery can ultimately result in a negative patient experience.

Clara C. Chan, MD, has received a retainer, ad hoc fees, or otherconsulting income from: Alcon,Bausch & Lomb, PRN, and Wyeth.She has received travel reimburse-ment from Alcon and is a memberof Allergan’s speakers bureau.

David A. Goldman, MD, hasreceived a retainer, ad hoc fees, or other consulting income from:Alcon, Allergan, Bausch & Lomb,Gerson Lehman Group, LeerinkSwann & Co., ModernizingMedicine, Ophthalmologyweb.com,and SARCode.

Bonnie An Henderson, MD, hasreceived a retainer, ad hoc fee, orother consulting income from:Alcon and ISTA.

Edward J. Holland, MD, hasreceived a retainer, ad hoc fees, orother consulting income from andis a member of the speakersbureau of: Abbott, Alcon, Bausch &Lomb, Senju Pharma, andTearScience. He has receivedtravel reimbursement from Alconand Bausch & Lomb, and hasreceived research funding fromAlcon.

Staff member Laura Johnson hasno financial interests to disclose.

Surgical stress begins prior toincisions and is influenced bymany factors during surgery,some of which are beyond thesurgeon’s control. This stress

triggers a cascade of metabolic eventsthat results in increased inflammation.Nonsteroidal anti-inflammatory drugs(NSAIDs) and corticosteroids act at differ-ent and synergistic parts of the inflam-matory cascade, thus they can beeffective when used in combination.

Sources of surgical stressThere are three sources of surgical stress:the incision, epithelial trauma, and endothelium loss. Epithelial trauma iscaused by dilation and anesthetic dropsand the povidone iodine preparation.Additionally, there is endothelium loss.There is more endothelial cell loss if theaxial length is shorter or if the phacotime is longer. The type of incision (scleral tunnel or clear corneal incisions)also plays a role in the amount of endothelium loss.

Whenever ultrasound energy isused, there is the potential for woundburn. My colleagues and I published astudy to determine the risk factors forwound burn.1 We found that the risk ofwound burn decreased 45% with a dou-bling of surgical volume. Additionally,exothermic viscosurgical devices (disper-sive viscoelastics) seem to create moreheat production than the cohesive forms.Phaco techniques also play a role. Di-vide-and-conquer takes more time and

uses more energy than chopping tech-niques. Therefore, the risk of woundburn with divide-and-conquer is higher.Risk was not found to be related to themachine used.

Foreign substances also have an effect. For example, povidone iodine istoxic if it inadvertently enters the ante-rior chamber. Toxic anterior segmentsyndrome has been reported with the useof the generic form of trypan blue. Intra-cameral antibiotics can also cause surgi-cal stress, if there is dilution error or thewrong pH level. This has been reportedwith the intracameral use of both cefuroxime and vancomycin.

Surgical difficulties—dense nucleus,broken capsule, retained nucleus or cor-tex, iris turbulence and trauma, floppyiris syndrome or zonular damage, intra-operative miosis—can also cause surgicalstress.

The inflammatory cascadeCertainly, prostaglandins are the biggestmediator. They have been shown to in-crease leukocyte migration, pain stimula-tion, miosis, vasodilation, vascular permeability, and disruption of the blood-aqueous barrier causing increased cell and flare reaction.

There are two strategies to avoid thesynthesis and release of pro-inflamma-tory mediators: use steroids to stop itearly in the cascade and use NSAIDs tostop it later in the cascade.

Steroids inhibit phospholipase A2early on in the inflammatory cascade to

prevent the release of arachidonic acidfrom cell membrane phospholipids.

Later in the cascade, NSAIDs can acton the cyclooxygenase pathway (COX-1and COX-2) to inhibit conversion ofarachidonic acid to prostaglandins.

Certainly, a comprehensive strategyis better than just a single tactic. BecauseNSAIDs and corticosteroids act at differ-ent and synergistic parts of the inflam-matory cascade, they can be veryeffective when used in combination.

Understanding surgical stress and the inflammatory cascadeby Clara C. Chan, MD

Reference1. Sorensen T, Chan CC, Bradley M, Braga-Mele R,Olson RJ. Ultrasound-induced corneal incision con-tracture survey in the United States and Canada. JCataract Refract Surg. 2012;38(2):227-233.

Dr. Chan is from the Department of Ophthalmology and Vision Sciences, University of Toronto. She can be contacted at clarachanmd@gmail.com.

Figure 2. Our patient profile is much different than it was 30 years ago.

Postoperative pain and inflammationPatients with certain pre-existing condi-tions (diabetes and autoimmune dis-

eases) are more likely to experience post-operative inflammation.

Postoperative pain can range from aforeign body sensation to moderate to se-vere pain. A study surveyed 306 patients

about their pain immediately aftercataract surgery.1 Interestingly, 37% ofthose surveyed had mild to moderatepain in the recovery room immediatelypostoperatively, and the postoperativepain was the most significant predictorof how satisfied they were with theircare. Postoperative pain was associatedwith low ratings of the quality of the surgical experience.

Today, speedy visual recovery ismore important than ever. Compared to30 years ago, people are living longer andworking longer, everyone has a cellphone, and everyone uses a computer, so patients require fast visual recovery(Figure 2).

Many people have unrealistic expec-tations because they have heard fromfriends that cataract surgery is not a bigdeal, they will see well immediately aftersurgery, and there should not be anypain. If the patient’s experience is differ-ent than this scenario, he or she is oftenconvinced that something went wrong.

In summary, corneal edema is un-predictable and can have an effect on

cataract patients’ postoperative recovery.Postoperative surgical pain is common,and even low levels of pain negatively af-fect patients’ perceptions of their surgery.

Reference1. Fung D, Cohen MM, Stewart S, Davies A. Whatdetermines patient satisfaction with cataract careunder topical local anesthesia and monitored seda-tion in a community hospital setting? Anesth Analg.2005;100(6):1644-1650.

Dr. Henderson is in private practice, Ophthalmic Consultants of Boston, and clinical professor of ophthalmology,Tufts University School of Medicine. She can be contacted at bahenderson@eyeboston.com.

continued from page 1

Demonstration of how corticosteroids and NSAIDs can inhibit different parts of theinflammatory cascade

Any inflammation reduces pa-tient satisfaction, so our goalshould be to eliminate, notjust reduce, inflammatoryside effects of cataract surgery.

We need to use the most potent therapiesavailable and adapt a regimen to encour-age compliance.

Surgeons need a multi-prongedstrategy that starts with preoperative pre-vention. This includes the use of topicalnonsteroidal anti-inflammatory drugs(NSAIDs) in high-risk cases and pulsedtopical corticosteroids on the day of sur-gery. It is also important to use a surgicaltechnique that minimizes trauma and apostoperative regimen that maximizespatient compliance and outcomes.

Medication strategiesI only use NSAIDs before the day of sur-gery and only in high-risk patients. Theyare valuable if they prevent miosis andallow surgeons to avoid iris hooks. Theyare also useful in cases where there is ahigh risk for inflammation. However, Itypically don’t use NSAIDs preoperativelyfor routine cataract surgery because mostpatients are only willing to use one bot-tle of medication, and I would ratherthat they extend the NSAID therapypostoperatively.

I do not use steroids or antibioticspreoperatively. Steroid use without an-tibiotics can increase bacterial over-growth on the ocular surface, andantibiotic use can select for resistantstrains preoperatively.

My regimenOn the day of surgery, patients receiveNSAIDs in the preoperative area. Patientsreceive one drop of difluprednate in theoperating room at the end of the caseand another drop in the recovery area. Ithen instruct them to instill anotherdrop when they get home. This pulseddose helps their eyes to be clear and comfortable by dinner time.

Postoperatively, patients use difluprednate once a day in the morningand nepafenac once a day in theevening. If patients have corneal edemaon postoperative day one, I give them anextra drop of difluprednate in the clinic.

Typical postop regimens include atapering dose of steroids over severalweeks and an NSAID regimen until the

bottle is gone. Patients appreciate theease of my regimen because it is one dropin the morning and one drop in theevening for the entire course of treat-ment. I think all patients benefit from aless frequent dosing regimen. They canleave their drops at home and not beconcerned about it during the day.

There are advantages and disadvan-tages to all of the currently availablesteroids. However, only difluprednateand loteprednol are available as emul-sions. Steroids that are available as suspensions must be shaken before use, and studies have shown that, evenwhen shaking the drops, the dose isvariable. Some doses are 50% of thelabel claim, while other doses are 200%of the label claim. In contrast, an emulsion will have the same amount of medication every time.

All NSAIDs can have corneal toxic-ity. One of the biggest concerns withNSAIDs is keratitis, and this may be dueto the analgesic effect that the NSAID hason the ocular surface. I prefer to dose theNSAID in the evening before patients goto sleep so that their eyes are closed afterinstillation.

The advantage of using both asteroid and an NSAID is the synergisticeffect on the inflammatory pathway. Because of this synergistic effect, we areable to use less of each medication, re-ducing the chance of an IOP spike andkeratitis, respectively. Additionally,steroids and NSAIDs are more effectivethan steroids alone in preventing CME,and preventing CME is much better thantreating CME in terms of visual out-comes.

Surgical techniqueSurgical technique is also important. We want to minimize phaco energy. Wewant to try to keep the phaco tip awayfrom the endothelium as much as possi-ble because it’s not just how much en-ergy is used but where it is being used. Ifa patient has endothelial compromise, asoft-shell technique is very effective, andit is important to make sure to remove allof the lens material.

Dr. Goldman is in private practice, PalmBeach Gardens, Fla. He can be contacted atdavid@goldmaneye.com.

Perioperative strategies toprevent inflammationby David A. Goldman, MD

Data from a survey of pre-registrants to this ASCRS inflammation symposium

CME Questions (Circle the correct answer)

Copyright 2013 ASCRS Ophthalmic Corporation. All rights reserved. The views expressed here do not necessarily reflect those of the editor, editorial board, or the publisher, and in no way imply endorsement by EyeWorld or ASCRS.

1. According to Dr. Henderson, the incidence ofclinical CME is approximately 1-2%; howeverthe incidence of angiographic CME is closerto:

a. 5-10%b. 10-20%c. 20-30%d. >30%

2. Studies have shown that the dosing aftershaking suspension steroids is consistent.

a. Trueb. False

3. According to a study surveying cataract patients, what was the most significant predictor of their satisfaction with care?

a. Visual acuity in recovery roomb. Postoperative painc. Length of visual recoveryd. Ability to read cell phone easily

4. Which of the following are the benefits of using a steroid and NSAID together to address the inflammation pathway?

a. Less medication usedb. Reduce the chance of an IOP spike and keratitisc. Increase the likelihood of preventing CMEd. All of the above

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