Anterior Segment Cataract
Alternative Pharmacotherapy Paradigm to Cataract Surgery Hon-Vu Q Duong, MD
Clinical Instructor of Ophthalmology, Westfield-Nevada Eye and Ear Center, Las Vegas, and Lecturer of Neuroscience, Anatomy and Physiology, Nevada State College, Henderson
Abstract
Cataracts are the leading cause of reversible blindness worldwide and cataract extraction is the treatment of choice and leads to an improvement in the quality of life. Surgical techniques are refined and complex and yield an extremely high rate of success with a short recovery period. To further maximize surgical outcomes, post-operative treatments of uncomplicated cataract extraction include three topical pharmaceutical agents: an antimicrobial, a potent corticosteroid, and a non-steroidal anti-inflammatory drug (NSAID). Studies have shown the importance of antimicrobial prophylaxis in reducing ocular infection and endophthalmitis with the use of the newer generation of fluoroquinolones. Furthermore, the usages of topical corticosteroids and NSAIDs have reduced and prevented anterior chamber inflammation and macular edema, respectively. The regimen, however, varies among ophthalmologists because of a lack of published data that establishes the optimal regimen. Although the technological advances in cataract extraction and intraocular lens (IOL) development are well documented, the pre-, peri-, and post-operative treatment paradigm since the 1970s and 1980s has not deviated much until recently, with the European Society of Cataract and Refractive Surgery endophthalmitis study and other studies addressing the necessity of topical steroid. Also rising costs, better surgical technologies, and advancements in IOL development, should ophthalmologists maintain a three-drug regimen post-surgery or tailor the post-operative management to the individual patient?
Keywords Cataract surgery, phacoemulsification, endophthalmitis, cystoid macular edema, bromfenac, ketorolac, nepafenac, topical steroids
Disclosure: The author has no conflicts of interest to declare. Received: October 17, 2011 Accepted: December 21, 2011 Citation: US Ophthalmic Review, 2012;5(1):48–52 Correspondence: Hon-Vu Q Duong, MD, 2575 Lindell Rd, Las Vegas, NV 89146. E:
hon-vu.duong@nsc.nevada.edu
The ‘standard of care’ is an interesting concept and one that is, to varying degrees, dictated not by scientific data but by the potentials for legal ramifications. The ‘standard of care’ can be equated to the column on the pantheon: once built, it is very difficult to tear down or modify. Ophthalmology as a surgical specialty does not escape this trap.
History of Cataract Surgery
Sushruta first described cataract surgery, in what was termed ‘couching’ in India, around the sixth century BCE in which the native cataractous lens is “pushed out of the field of vision.”1
In 1748, Jacques Daviel, a
French surgeon, made an incision in the cornea along the inferior limbus, incised the lens capsule, and expressed the lens material.1 In 1940, Harold Ridley, a Royal Air Force ophthalmologist, introduced the concept of implanting an artificial lens into the eye and in 1949 successfully implanted the first polymethyl methacrylate intraocular lens (IOL).1
In 1967, Charles Kelman introduced phacoemulsification, a technique that utilizes ultrasonic waves to emulsify the cataractous lens without having to make such large incisions during cataract extraction.1,2 The development of less-invasive surgical techniques, including lens extraction by ultrasound phacoemulsification, and improved instrumentation in the late 1970s and 1980s ushered in a new era for cataract surgery and IOL development.
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Phacoemulsification could be conducted through incisions of 3 mm or less, greatly reducing peri-operative morbidity and hastening the time to visual recovery. Concomitant advances in instrumentation allowed for a more complete removal of pro-inflammatory lens cortical material and for IOLs (toric, multifocal, and accommodating) to be placed more safely. Refinements in surgical technology yielded additional reductions in incision size, and sutureless wounds, while development of viscoelastic and IOLs yielded unprecedented levels of success in visual recovery and function. More recently, an emerging technology, ultra short-pulse lasers (femtoseconds), is gaining wide acceptance and appears to, once again, shift the paradigm in cataract and refractive surgery. Yet the management of post-cataract surgery has not changed significantly. Patients are given a topical antimicrobial pre- and post-surgery for endophthalmitis prophylaxis, and a topical steroid along with a non-steroidal anti-inflammatory drug (NSAID) to decrease inflammation and the incident of cystoid macular edema.3
With better technology, surgical training, and surgical techniques, we ask: “Is pre-operative topical antimicrobial and topical steroid necessary in post-uncomplicated cataract extraction?” Based on recently published data, the paradigm in pharmacological approach is shifting slowing.
© TOUCH BRIEFINGS 2012
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