Eyeworld CME Supplements

EW JUL 2013 - Supported by Bausch + Lomb

This is a supplement to EyeWorld Magazine that doctors can take a test after reading and receive CME credits for.

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achieve tissue levels before surgery, since it takes about three to five doses on average to achieve steady state (Figure 3). Preop dosing also attenuates the inflammatory response and gets patients in the habit of using drops. After surgery, both steroids and NSAIDs are indicated for use out to 14 days postop. Steroids in particular should be used to "hammer the inflammation"—hit inflammation hard with more frequent dosing initially, taking advantage of the immediate postop period when compliance is at its best. When the steroids are no longer needed, they should be tapered off, unlike NSAIDs, which are simply discontinued. Dr. Devgan's routine is to begin topical NSAIDs, steroids, and an antibiotic 3 days before surgery, continuing the NSAID out to 6 weeks, the steroid BID for 1 week followed by once a day for another week, and the antibiotic TID for 1 week after surgery. The bottom line, said Dr. Devgan, is "use your clinical judgment. Determine when the inflammation is resolved, and tailor the treatment to the patient." Postop recovery, he added, is as important as surgical technique. least one additional time between 2 and 4 weeks after surgery. He defined steroid responders as patients who underwent uncomplicated surgery but had an IOP measurement of at least 28 mm Hg beyond the first 72 hours after surgery, to exclude surgical factors such as retained OVD or corneal edema. Exclusion criteria included any hyphema, endophthalmitis, or TASS. "We decided to use 28 mm Hg as our threshold because many of us would alter or initiate treatment at this IOP level," Dr. Chang explained. To be sure that it was drug induced, an IOP elevation of ≥25% on steroid and an IOP drop of ≥25% off steroid was required for the patient to be classified as a steroid responder. After excluding patients who were not prescribed steroids (e.g., known responders, herpetic eye disease), a total number of 1,613 consecutive patients had uncomplicated surgeries and were taking topical steroids postoperatively. Of these patients, 39 (2.4%) had IOPs of ≥28 mm Hg, 15 (0.9%) had IOPs of ≥35 mm Hg, and 7 (0.4%) had IOPs in the range of 40-68 mm Hg. Of the 7 patients with alarmingly high IOPs, 6 were <65 years old, 4 were high myopes, and 6 were diagnosed early—between 5 and 14 days after surgery. Of the 39 patients exceeding the threshold 28 mm Hg IOP for steroid response, only 6 had a known risk factor—open-angle glaucoma. This left 85% without any known risk factors. By analyzing the 39 steroid respon- Risk factors for steroid response among cataract patients In his own private practice, David F. Chang, MD, clinical professor of ophthalmology, University of California, Los Altos, Calif., had noticed how an occasional patient would present with an alarming increase in IOP shortly after cataract surgery. "The IOP would be up to 50 or 60 mm Hg, and the patients had called because their vision was blacking out when they would bend over," he said. "They always seemed to be young, really high myopes, and they might present less than one week following uncomplicated surgery." Dr. Chang diagnosed these patients as steroid responders because these were pressure spikes following normal postop day 1 tonometry, and the pressure would normalize after stopping the topical steroid. Dr. Chang described the results of a retrospective study he conducted to identify the risk factors in these cases, presenting data recently published in the Journal of Cataract & Refractive Surgery.7 "If you review the literature, the only published risk factor for a steroid response is open-angle glaucoma," he said. In a chart review covering a 2-year period, Dr. Chang and his colleagues gathered data on 1,642 consecutive patients. All the patients underwent phacoemulsification with IOL implantation and had received a uniform treatment regimen of 1% prednisolone acetate three times a day for 2 weeks, then twice a day for 2-3 weeks. Each patient also received a topical NSAID and an antibiotic. Dr. Chang analyzed age and axial length measurements using the IOLMaster, always taking the first eye in a bilateral cataract surgical patient. IOP measurements were recorded preop, at postop day 1, and at Figure 4. Cumulative % steroid responders by age and axial length Figure 5. Steroid responder odds ratios, with treatment stratification by risk

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