Journal Reading

Effect of Intracameral Phenylephrine

1.0%-ketorolac 0.3% on postoperative
Cystoid Macular Edema, Iritis, Pain and
Photophobia after Cataract Surgery

Denise M. Visco, MD, MBA, Raman Bedi, MD

From The Eyes Of York Cataract & Laser Center Departemen Ilmu Kesehatan Mata
(Visco), York, Pennsylvania, Usa; Irisarc (Bedi), Fakultas Kedokteran
Chandigarh, India. Universitas Hasanuddin

1
 Content
01 Abstract

02 Journal Theory

03 Introduction

04 Material and Methods

05 Result

06 Discussion
2
Abstract
ABSTRACT

• Purpose
• Design
• Methods
• Main Outcome
Measures
• Conclusion

3
 Purpose

To assess the effectiveness of intracameral

phenylephrine–ketorolac during cataract
surgery compared with postoperative topical
steroids in reducing the incidence of
postoperative clinical cystoid macular edema
(CME) confirmed via optical coherence
tomography (OCT), breakthrough iritis, pain,
and photophobia

4
 Design

Retrospective 2-cohort study

5
 Methods

Compare incidence of postoperative CME,

breakthrough iritis, pain and photophobia between
patients receiving either intracameral
phenylephreine 1&-ketorolac 0.3% during surgery or
topical loteprechol 0.5% 2 days preoperatively,
tapered postoperatively

All eyes received bromfenac 2 days preoperatively &

10 weeks postoperatively

6
 Results
 This study enrolled 2218 eyes (n = 1402).
 The phenylephrine/ketorolac treatment group included
1334 eyes (n = 830) and the topical loteprednol control
group included 884 eyes (n = 572). The groups were
comparable in age, race, gender, and perioperative
characteristics
 Clinical CME, breakthrough iritis and pain were
significantly lower in the phenylephrine–ketorolac
group than the topical loteprednol group.
 incidence of photophobia trended lower for the
phenylephrine/ketorolac group relative to the topical
loteprednol group but was not statistically significant.

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 Conclusion

Intracameral phenylephrine/ketorolac and topical

nonsteroidal antiinflammatory drugs (NSAIDs)
without postoperative topical steroids significantly
reduced postoperative clinical CME, breakthrough
iritis, and pain after cataract surgery when compared
with conventional perioperative topical steroids and
NSAIDs.

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JOURNAL
THEORY

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 CATARACT

• Etymologically  a Age-related cataracts

are responsible for
descent of water over a
51% of world blindness
steep surface; a waterfall (WHO)

• An abnormality of the eye,

characterized by opacity of
the lens

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CATARACT : Sign & symptoms

11
CATARACT : types of cataract

12
CATARACT : causes

13
CATARACT : treatment

14
 Post-operative complication after
cataract surgery
OPERATIVE COMPLICATION
 Acute postoperative
endophthalmitis
 Delayed onset postoperative
endophthalmitis
 Posterior capsular opaciification
 Lens-induced uveitis
 Anterior capsular fibrosis and
contraction
MISCELLANEOUS POSTOPERATIVE
COMPLICATIONS
 Cystoid macular edema (CME)
 Dysphotopsia
 Corneal decompensation
 Ptosis
 Malposition of the IOL
 Retinal detachment
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Post-operative complication after Lens-induced
cataract surgery uveitis

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 Post-operative complication after Lens-induced
cataract surgery uveitis
Clinical features
 Symptoms : variable pain, photophobia,
redness and bluring, with a history of recent
cataract surgery or injury
 Signs : corneal edema is common adjacent to
an anterior chamber lens fragment, IOP is
frequently elevated, lens fragment may be
visible in the anterior or posterior segment

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 Post-operative complication after Lens-induced
cataract surgery uveitis
TREATMENT
 Steroids (the route & intensity dependent on
clinical circumstances)
 Surgical remobal of all lens material from
anterior chamber or via pars plana vitrectomy
as required
 Small fragment  treated conservatively and
will absorb slowly over months
 Cycloplegics + IOP lowering drugs

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 Post-operative complication after Cystoid
cataract surgery Macular
 Definition : accumulation of fluid in the outer Edema
plexiform & inner nuclear layers of the retina with
the formation of tiny cyst-like cavities

1903/25/21
Post-operative complication after Cystoid
cataract surgery Macular
Edema

2003/25/21
 Post-operative complication after Cystoid
cataract surgery Macular
Edema
Clinical features & Diagnosis

Signs : Loss of foveal depression, thickening of the retina

and multiple cystoids areas in the sensory retina,
sometimes optic disc swelling, a lamellar hole maybe
visible

Clinical modalities
Amsler grid  central blurring & distortion
OCT : retinal thickening with cystic hyporeflective
spaces and loss of foveal depression

2103/25/21
 Post-operative complication after Cystoid
cataract surgery Macular
Edema
TREATMENT
 Anterior vitrectomy or YAG laser vitrotomy to vitreous
incarceration in the anterior segment if present
 Topical NSAIDs
 Steroid, topically, by periocular or intravitreal
 Carbonic anhidrase inhibitors given systematically or topically
 Intravitreal anti-VGEF agents
 Pars plana vitrectomy  CME refractory to medical therapy

2203/25/21
BACK TO JOURNAL

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 Introduction
Modern Cataract surgery is
generally safe and effective

 However, postoperative
inflammation & associated Neatrouer et al : 1.75% incidence of
complications remain as common persistent iritis after cataract surgery
cause of delayed healing,
discomfort, pain, anxiety Incidence of post-cataract CME ranges
 In case of significant inflammation, from 0.1% to 4.5%
a cystoid macular edema (CME) can
be sight-threatening

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 Introduction
Risk factors for developing post-operative complications

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 Introduction
Arachidonic acid cascade and postoperative complication
 Stimulation of arachidonic
acid cascade causes
breakthrough iritis and CME
through activation of
cyclooxygenase-1 (COX-1)
and COX-2

 Topical corticosteroid and

NSAIDs are COX inhibitors
frequently used to prevent
or treat post-operative
inflammation
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 Introduction
Omidria, a FDA-approved drug
containing a combination of
phenylephrine 1.0%-ketorolac
0.3% provides continous
intracameral administration
during cataract surgery

Ketorolac  could Phenylephrine  help maintain

effectively block mydriasis throughout cataract
inflammatory cascade than surgery
topical NSAIDs alone
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MATERIALS AND METHODS

Aim and
study design

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 MATERIALS AND METHODS
INCLUSION CRITERIA EXCLUSION CRITERIA

Participant
1. Patients who underwent 1. Patients with prior CME,
selection cataract surgery combined
criteria cataract/glaucoma surgery
1. Available follow up data for and have medication
at least the 1-day, 2-week protocol different from this
and 6-week routine post study
operative visits
2. Patients whose eyes were at
high risks for postoperative
CME

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 MATERIALS AND METHODS
TREATMENT GROUP
All patients met the inclusion
criteria treated with
Study intracameral phenylephrine
1.0%-ketorolac 0.3%
participants intraoperatively to replace
topical corticosteroid drops
CONTROL GROUP
Conventional corticosteroid
protocol was applied as
followed
•1 drop of loteprednol 0.5%
q.i.d 2 days before surgery and
up to 1 week after surgery
•Then tappered: t.i.d in the 2nd
week, b.i.d in 3rd week and
once a day in 4th week

All patients in both groups were received bromfenac oftalmic solution

0.07% for 2 days prior to surgery and 10 weeks postoperatively
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MATERIALS AND METHODS
OUTCOMES

1. Diagnosis of postoperative
inflammatory complications
(CME & breakthrough iritis) &

2. patient discomfort (pain &

photophobia) at any point
after post-operative day 1
through postoperative day 90

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MATERIALS AND METHODS Analyzed Variables
 PREOPERATIVE CHARACTERISTICS : basic demographics &
laterality
 OPERATIVE CHARACTERISTICS : femtosecond laser-
assisted vs conventional procedure, creation of astigmatic
incisions, posterior capsular tear, intraoperative floppy-iris
syndrome, corneal edema, retinal detachment, retained
lens fragment, and use of trypan blue/indocyanine green
dye
 PATIENT’S CHARACTERISTICS : concomitant medication
(alpha-blocker, prostaglandin analogue, or anti-VEGF
medication within last 90 days), comorbidities and prior
ocular events (vitreous hemorrhage, retinal detachment,
ocular trauma)

3203/25/21
33

RESULTS

33
RESULTS A total of 2218 eyes of 1402 patients
(831 women and 571 men) met
recruitment criteria
STUDY GROUP CONTROL GROUP
•1334 eyes of 830 patients •884 eyes of 572 patients

Both groups were comparable in terms of race, gender (Table 2), and
perioperative patient characteristics (Table 3). 34
RESULTS

OPERATIVE
CHARACTERISTICS

35
RESULTS POSTOPERATIVE
 Incidence of CME was
OUTCOMES
significantly lower in the
treatment group (0.52% vs
1.47%, P = .021).
 incidence of breakthrough
iritis was also significantly
lower (1.72% vs 4.86%, P < .
001) in the treatment group
than in the control group.
 incidence of pain (as
documented in patient
charts) was significantly
lower (1.27 vs 4.19%, P < .
001) in the treatment group

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37

DISCUSSION

37
Post-cataract control of inflammation : NSAIDs or steroid?

There is a growing evidence to suggest that topical NSAIDs may be good

as or better than steroids in preventing post-operative inflammation while
avoiding the undesirabel effects of cotricosteroid (increased IOP, delayed
wound healing )

3803/25/21
Post-cataract control of inflammation : New strategy

The introduction of phenylephrine

1.0%–ketorolac 0.3%, which is the
first FDA-approved drug to deliver
an NSAID intracamerally, served as
an opportunity for our practice to
reduce the burden of routine
perioperative corticosteroid drops

3903/25/21
Post-cataract control of inflammation : New strategy
Administration of intraoperative intracameral phenylephrine 1.0%–
ketorolac 0.3%
 Intraoperative ketorolac 
induce blockage of COX
pathway  inhibits
inflammation

 Phenylephrine 
maintenance of pupil size
contributes to reduction of
surgical trauma during
surgery

40
Outcomes and comorbidities

4103/25/21
 Outcomes : Postoperative pain
THIS STUDY:
PREVIOUS STUDY:
phenylephrine–ketorolac study
Intracameral
group showed a significantly
phenylephrine 1.0%
lower incidence of postoperative
ketorolac 0.3% has
pain through 90 days postsurgery
previously been
compared with the control group
shown to reduce
(1.27% vs 4.19%, P < .001) based
pain up to 12 hours
on the retrospective review of
after the cataract
pain reports in patient charts
extraction

4203/25/21
 Outcomes : Photophobia
THIS STUDY:
• Photophobia is
poorly defined
Photophobia was considered
and understood,
positive for any patient who
patients report
complained of light of sensitivity
are highly
at any time post-operatively 
variable
need to check for signs
This study was retrospective, inflammation
other confounding factors Photophobia is not closely
(external eye condition, correlated with ocular
migrain, etc) should be taken
inflammation
into account as cause of
photophobia
4303/25/21
 The current study outcomes suggest that phenylephrine
1.0%–ketorolac 0.3% may be a good addition to the
cataract surgery pharmaceutical regimen.

 When combined with perioperative topical NSAIDs, it may

be a better prophylactic regimen for postoperative CME,
iritis, and pain than regimens involving compliance-
dependent topical steroids with topical NSAIDs.

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