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 Table of Contents  
LETTER TO EDITOR
Year : 2022  |  Volume : 34  |  Issue : 3  |  Page : 385-386

Reply to Letter to Editor: Prophylactic Use of Nonsteroidal Anti-Inflammatory Drugs after Cataract Surgery and Corneal Melt


1 Sussex Eye Hospital, University Hospitals Sussex NHS Foundation Trust, Brighton, United Kingdom
2 Sussex Eye Hospital, University Hospitals Sussex NHS Foundation Trust; Brighton and Sussex Medical School, University of Sussex, Falmer, Brighton, United Kingdom
3 Sussex Eye Hospital, University Hospitals Sussex NHS Foundation Trust, Brighton; Department of Ophthalmology, Northampton General Hospital NHS Trust, Cliftonville, Northampton, United Kingdom
4 Department of Ophthalmology, Northampton General Hospital NHS Trust, Cliftonville, Northampton, United Kingdom

Date of Submission19-Jun-2022
Date of Acceptance26-Jun-2022
Date of Web Publication30-Nov-2022

Correspondence Address:
Mayank A Nanavaty
Sussex Eye Hospital, University Hospitals Sussex NHS Foundation Trust, Eastern Road, Brighton, BN2 5BF
United Kingdom
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joco.joco_176_22

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How to cite this article:
Ashena Z, Nanavaty MA, Bardan AS, Thaker R, Bascaran L. Reply to Letter to Editor: Prophylactic Use of Nonsteroidal Anti-Inflammatory Drugs after Cataract Surgery and Corneal Melt. J Curr Ophthalmol 2022;34:385-6

How to cite this URL:
Ashena Z, Nanavaty MA, Bardan AS, Thaker R, Bascaran L. Reply to Letter to Editor: Prophylactic Use of Nonsteroidal Anti-Inflammatory Drugs after Cataract Surgery and Corneal Melt. J Curr Ophthalmol [serial online] 2022 [cited 2023 Feb 4];34:385-6. Available from: http://www.jcurrophthalmol.org/text.asp?2022/34/3/385/362454



We thank the authors for their interest in our article entitled “Prophylactic use of nonsteroidal anti-inflammatory drugs after cataract surgery and corneal melt”.1 They refer to Cabourne et al.'s report of 5 corneal melt and one perforation following the use of combined dexamethasone/neomycin (Maxitrol®, Alcon Laboratories, Dublin, Ireland) and ketorolac after routine cataract surgery,[2] and caution against the use of this combination in diabetic patients, given the well-reported risks of prescribing topical nonsteroidal anti-inflammatory drugs (NSAIDs) alongside neomycin or tobramycin. We read with interest the reduced rate of corneal melt in their patients in the past 6 years with the separate prescriptions of dexamethasone (Maxidex®, Alcon Laboratories, Dublin, Ireland), chloramphenicol, and ketorolac in diabetic patients following cataract surgery.

Looking at the literature, the corneal melt has been reported with topical administration of all types of topical NSAIDs alongside topical steroids and different antibiotics. Ting and Ghosh reported a case of corneal melt following uneventful cataract surgery and prescription of topical prednisolone, ketorolac, and chloramphenicol.[3] Jesus et al. reported a corneal perforation following cataract surgery with the administration of dexamethasone, gentamicin, and ketorolac.[4] Similarly, the corneal melt has been reported with other topical NSAIDs such as nepafenac, diclofenac, and bromfenac alongside topical steroids and antibiotics such as chloramphenicol, levofloxacin, and moxifloxacin after cataract surgery.[5],[6] Therefore, although this is a rare complication, the evidence shows an increased risk of corneal perforation with the topical administration of NSAIDs and steroids in the presence or absence of topical tobramycin, neomycin, or the combined drugs of dexamethasone/neomycin (Maxitrol®, Alcon Laboratories, Dublin, Ireland) and dexamethasone/tobramycin (Tobradex®, Alcon Laboratories, USA). We are pleased to understand the rate of corneal perforation in diabetic patients who received prophylactic topical NSAID following cataract surgery at Moorfields has decreased. However, this may be secondary to multiple factors, including general precaution in treating the dry eye and optimizing the ocular surface before cataract surgery, after report of the previous corneal melt cases, as well as increased popularity and accessibility of the preservative-free eye drops, which are known to induce less epithelial toxicity, in the past few years.

Moreover, it is already known that diabetes, dry eye, and topical NSAIDs will influence corneal sensitivity individually and make the cornea neurotropic.[7],[8],[9] Furthermore, the link between diabetes and dry eye has already been established.[7] Furthermore, topical steroids are known to worsen corneal melting clinically.[10] Therefore, any toxicity of any topical antibiotic is likely to be aggregated into a neurotrophic ulcer or melt rapidly in the background of diabetes, dry eyes, and topical administration of steroids and NSAIDs. Therefore, we agree with Shalchi et al. that intravitreal delivery of steroids for co-management of existing/impending of cystoid macular edema (CMO) may be a better option. A blanket protocol of using topical NSAIDs in combination with antibiotics/steroids as prophylaxis should be used with caution and close monitoring with judicious patient selection and optimization of the ocular surface comorbidities, with particular emphasis on patients with systemic autoimmune conditions.

With regards to Shalchi et al.'s comment on the management of CMO, since our paper focused on the prophylactic use of topical NSAIDs and not the management of CMO in diabetic patients, we will refer our readers to the published guidelines on this matter.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ashena Z, Nanavaty MA, Bardan AS, Thaker R, Bascaran L. Prophylactic use of nonsteroidal anti-inflammatory drugs after cataract surgery and corneal melt. J Curr Ophthalmol 2021;33:485-91.  Back to cited text no. 1
  [Full text]  
2.
Cabourne E, Lau N, Flanagan D, Nott J, Bloom J, Angunawela R. Severe corneal melting after cataract surgery in patients prescribed topical postoperative NSAIDs and dexamethasone/neomycin combination therapy. J Cataract Refract Surg 2020;46:138-42.  Back to cited text no. 2
    
3.
Ting DS, Ghosh S. Acute corneal perforation 1 week following uncomplicated cataract surgery: The implication of undiagnosed dry eye disease and topical NSAIDs. Ther Adv Ophthalmol 2019;11:2515841419869508.  Back to cited text no. 3
    
4.
Jesus J, Almeida I, Soares R, Geraldes R, Chibante-Pedro J. Corneal perforation associated with the use of ketorolac tromethamine after cataract surgery. J EuCornea 2020;6:1-3.  Back to cited text no. 4
    
5.
Wolf EJ, Kleiman LZ, Schrier A. Nepafenac-associated corneal melt. J Cataract Refract Surg 2007;33:1974-5.  Back to cited text no. 5
    
6.
Harada K, Mohamed YH, Uematsu M, Inoue D, Ueki R, Harada S, et al. Three cases of acute sterile corneal melt after cataract surgery. Am J Ophthalmol Case Rep 2019;13:62-5.  Back to cited text no. 6
    
7.
Zhou T, Lee A, Lo AC, Kwok JS. Diabetic corneal neuropathy: Pathogenic mechanisms and therapeutic strategies. Front Pharmacol 2022;13:816062.  Back to cited text no. 7
    
8.
Singer DD, Kennedy J, Wittpenn JR. Topical NSAIDs effect on corneal sensitivity. Cornea 2015;34:541-3.  Back to cited text no. 8
    
9.
Toker E, Asfuroğlu E. Corneal and conjunctival sensitivity in patients with dry eye: The effect of topical cyclosporine therapy. Cornea 2010;29:133-40.  Back to cited text no. 9
    
10.
Bonini S, Rama P, Olzi D, Lambiase A. Neurotrophic keratitis. Eye (Lond) 2003;17:989-95.  Back to cited text no. 10
    




 

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