Commentary: Let us ponder - Choosing between topical Nepafenac and topical steroids after cataract surgery.

During cataract surgery, there is cutting and incisions of ocular tissue, and manipulation of intraocular structures, that lead to the breaking down of the blood-aqueous barrier. There can be an outpouring of fibrin and inflammatory cells into the anterior chamber which characterizes as the anterior chamber reaction, which if severe and uncontrolled, can become sight-threatening and distressing for the patient.[1] Topical steroids have been the mainstay in preventing and controlling this reaction. However, a rise in intraocular pressure, risk of infection, and delayed healing have been some of the concerns with topical steroids. Following these concerns, NSAIDs (non-steroidal anti-inflammatory drugs) like ketorolac, flurbiprofen, bromfenac, and more recently, nepafenac 0.1% were used. Nepafenac is chemically a 2-amino-3-benzoyl benzeneacetamide, a prodrug of the active form of the drug amfenac. It is manufactured as a 0.1% ophthalmic suspension.[2] It acts by non-selective inhibition of COX (cyclooxygenase) enzymes, thus, blocking the production of pro-inflammatory eicosanoids—mainly prostaglandins.

Efficacy of nepafenac in preventing postoperative inflammation

Nepafenac quickly re-establishes the blood-aqueous barrier after surgery. Used perioperatively, it helps in preventing intraoperative miosis. Pseudophakic cystoid macular edema (PCME) has an incidence of around 1.17% after uncomplicated phacoemulsification surgery.[3] The risk is further raised in diagnosed diabetics. Nepafenac helps in preventing PCME, and in fact, should be prescribed in all diabetics undergoing cataract surgery.[4]

Precautions regarding nepafenac use

Nepafenac can interfere with the healing of corneal epithelium in case of corneal epithelial defects. It also should be used carefully or withdrawn in the eyes with ocular surface diseases or dry eye diseases, neurotrophic keratopathy, and multiple ocular surgeries.[5]

Being an NSAID, it can interfere with thrombocyte aggregation and prolong bleeding time in patients on medications that prolong the bleeding time. It is hence to be used cautiously in them as well as in those with bleeding diathesis.[5]

Comparison between topical steroids and topical nepafenac

Nepafenac 0.1% was found equally effective as 1% prednisolone acetate topically in the suppression and prevention of inflammation post-surgery.[6] Both are effective in suppressing lid edema and conjunctival congestion. Regarding pain control, nepafenac scores better and is an advantage. Steroids may be associated with a rise in intraocular pressure and delayed wound healing.

What to choose – nepafenac or steroids?

Nepafenac can be given in all uneventful phacoemulsification surgeries, glaucoma, steroid responders, eyes with macular edema or thickening, and those with a high risk of postoperative infections. Whereas, in cases with corneal epithelial problems, bleeding diathesis, and in complicated surgeries and pediatric cases, steroids should be given.

To conclude, steroids have stood the test of time, and their role in postoperative care remains dominant. The surgeon decides what to choose.

Future directions to explore?

Whether nepafenac can be used in complicated cataract cases? Is nepafenac safe and effective in children? These are some areas that need to be dived into.

The current article compares 0.1% nepafenac thrice a day to 0.3% nepafenac once a day formulation, following cataract extraction—an attempt to reduce dosing and improve compliance in patients.[7]