Comparative Effectiveness of Prophylaxis for Cystoid Macular Edema After Phacoemulsification Surgery
Purpose
To compare rates of acute, clinical postoperative cystoid macular edema (CME) in relation to prophylaxis using post-operative topical prednisolone alone or with non-steroidal anti-inflammatory drug (NSAID), or subconjunctival injection of 2 mg triamcinolone acetonide at the conclusion of phacoemulsification surgery.
Methods
Review of electronic records of patients undergoing cataract surgery diagnosed with CME within 4 months of surgery. Patients with a prior history of macular edema or glaucoma were excluded. CME was validated by the research ophthalmologist for eyes with visual acuity of 20/40 or worse and with ocular coherence tomographic evidence of central macular thickening or cystoid spaces. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were obtained from logistic regression analysis after accounting for year of surgery, patient age, Charlson comorbidity, history of glaucoma, age-related macular degeneration, diabetic retinopathy, epiretinal membrane, or iritis, and posterior capsular rupture (PCR).
Results
We confirmed 148 cases of CME among 19,258 cataract surgeries (incidence, 0.77%). Compared with use of topical prednisolone alone, the adjusted OR for the relationship of CME with use of topical prednisolone with NSAID was 0.47 (CI, 0.30-0.74); for triamcinolone acetonide, it was 0.88 (CI 0.53-1.47). The apparent benefit for NSAID was observed for diclofenac and flurbiprofen, but not ketorolac (compared with prednisolone alone, OR 1.01 with CI 0.52-1.99). The benefit was similar for patients with or without diabetic retinopathy, epiretinal membrane, iritis, or PCR.
Conclusion
Addition of diclofenac or flurbiprofen, but not ketorolac, was associated with reduced risk of CME in patients with and without key ocular comorbidities. Protection with triamcinolone acetonide injection was similar to protection with prednisolone alone, while avoiding adherence issues, dropper tip contamination, trauma to the eye, and patient inconvenience.