Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used and studied by cataract surgeons for different benefits in the perioperative period, but optimal medication formulae and dosing have yet to be established. In this article, we perform a literature review of articles published between 1 January 2016 and 30 June 2018 concerning perioperative NSAID use for patients undergoing cataract surgery.

Nonsteroidal anti-inflammatory drugs (NSAIDs), a class of medications that inhibit cyclooxygenase (COX) enzymes from producing pro-inflammatory prostaglandins, have multiple indications in the perioperative period including pain control, reducing inflammation, improving intraocular mydriasis, and preventing postoperative cystoid macular edema (CME).

Although the potential benefits of NSAIDs in the perioperative period have been known for years, optimal NSAID medication and dosing regimens have yet to be established. This article reviews the literature concerning perioperative NSAID use between 1 January 2016 and 30 June 2018. A literature review revealed five areas of recent study including preoperative NSAID use for iatrogenic inflammation, intraoperative NSAID use for pupillary mydriasis, postoperative NSAID use for prevention of cystoid macular edema (CME), for prevention of pain/inflammation, and improvement in patient quality of life.

Recent literature establishes the efficacy of a newly available intracameral phenylephrine NSAID combination for pupillary mydriasis, postoperative NSAID use for preventing CME in specific high-risk populations, and postoperative NSAIDs for controlling pain and inflammation. However, further high-quality studies are required to determine the long-term effects of perioperative NSAIDs on visual acuity and CME rates.

Preoperative Nonsteroidal Anti-inflammatory Drug use

Many cataract surgeons begin NSAID medications for their patients preoperatively to reduce intraoperative prostaglandin release and blunt postoperative inflammation. In 2017, Katsev et al. obtained serial 100 μl samples of aqueous humor in 12 patients undergoing cataract surgery. Samples were obtained from patients who had received topical ketorolac three times over 24 h before surgery and were collected both after initial paracentesis and before corneal wound hydration.

Ketorolac concentrations were significantly reduced at the end of surgery compared with the beginning of operation (P = 0.0022) with 66.7% of patients having undetectable levels at the end. Although the possible depot effect of preoperative ketorolac dosing in the vitreous cavity remains unclear, the authors noted that ketorolac's short half-life of 2.3 h and the removal of the free drug by intraoperative irrigation likely renders the postoperative anti-inflammatory effects of preoperative ketorolac minimal. Therefore, they advocated for intraoperative ketorolac use.

The best use of perioperative NSAIDs continues to be a source of debate in the ophthalmologic literature. Reviewing articles published between 1 January 2016 and 30 June 2018 revealed new developments at every stage of cataract surgery. Perioperative NSAIDs achieve better intraoperative mydriasis, lower rates of postoperative CME, and improve patient comfort following surgery. Further high-quality studies are needed to establish Level I evidence on the long-term effects of perioperative NSAIDs on visual acuity and CME rates in low-risk and high-risk patients.