John R. Wittpenn

A Randomized, Masked Comparison of Topical Ketorolac 0.4% Plus Steroid vs Steroid Alone in Low-Risk Cataract Surgery Patients

PURPOSE To evaluate whether adding perioperative topical ketorolac tromethamine 0.4% improves cataract surgery outcomes relative to topical steroids alone in patients without known risk factors for cystoid macular edema (CME). DESIGN Prospective, randomized, investigator-masked, multicenter clinical trial. METHODS Patients scheduled to undergo phacoemulsification and with no recognized CME risks (diabetic retinopathy, retinal vascular disease, or macular abnormality) were randomized to receive either prednisolone acetate 1% 4 times daily (QID) alone (steroid group; n = 278) or prednisolone 1% QID plus ketorolac 0.4% QID (ketorolac/steroid group; n = 268) for approximately four weeks postoperatively. In the ketorolac/steroid group, patients also received topical ketorolac 0.4% QID for three days preoperatively. In both groups, patients received four doses of ketorolac 0.4% one hour before surgery. Patients with capsular disruption or vitreous loss intraoperatively were exited from the study. Outcome measures included CME incidence, retinal thickness as measured by optical coherence tomography (OCT), best-corrected visual acuity, and contrast sensitivity. RESULTS No patients in the ketorolac/steroid group and five patients in the steroid group had clinically apparent CME (P = .032). Based on OCT, no ketorolac/steroid patient had definite or probable CME, compared with six steroid patients (2.4%; P = .018). In the ketorolac/steroid group, mean retinal thickening was less (3.9 microm vs 9.6 microm; P = .003), and fewer patients had retinal thickening of more than 10 microm as compared with the steroid group (26% vs 51%; P < .001). CONCLUSIONS This study suggests that adding perioperative ketorolac to postoperative prednisolone significantly reduces the incidences of CME and macular thickening in cataract surgery patients already at low risk for this condition.

Preoperative ketorolac tromethamine 0.4% in phacoemulsification outcomes: Pharmacokinetic-response curve

PURPOSE: To assess the clinical benefit, relative efficacy, and pharmacokinetic‐response curve of preoperative and postoperative ketorolac tromethamine 0.4% (Acular LS) to improve outcomes during and after cataract surgery. SETTING: Private clinical practice. METHODS: One hundred patients were randomized in a double‐masked fashion to 4 groups of 25 to receive ketorolac for 3 days, 1 day, or 1 hour or a placebo before phacoemulsification. All treatment groups received ketorolac 0.4% for 3 weeks postoperatively; the placebo group received vehicle. Outcomes measures were preservation of preoperative mydriasis, phacoemulsification time and energy, operative time, corneal clarity, endothelial cell counts, postoperative inflammation, intraoperative and postoperative discomfort, complications, and incidence of clinically significant cystoid macular edema (CME). RESULTS: Maintenance of pupil size with 3‐day ketorolac dosing was significantly better than with 1‐day dosing (P<.01), which was significantly better than with 1‐hour or placebo dosing (P<.01). Both 3‐day and 1‐day dosing were superior to 1‐hour or placebo dosing. No patient receiving ketorolac 0.4% for 1 or 3 days developed CME compared with 12% of patients in the control (placebo) group and 4% in the 1‐hour group. Three‐day and 1‐day dosing of ketorolac reduced surgical time, phacoemulsification time and energy, and endothelial cell loss and improved visual acuity in the immediate postoperative period compared with 1‐hour predosing and the placebo (P<.05). CONCLUSION: The preoperative use of ketorolac tromethamine 0.4% for 3 days followed by 1‐day of predosing provided optimum efficacy and superior outcomes relative to 1‐hour pretreatment and a placebo.

A Comparison of Gatifloxacin to Ciprofloxacin in the Prophylaxis of streptococcus pneumoniae in Rabbits in a Lasik Model

Purpose. To investigate the efficacy of the fourth-generation fluoroquinolone, gatifloxacin 0.3%, compared to ciprofloxacin 0.3%, in preventing Streptococcus pneumoniae keratitis in a rabbit laser in situ keratomileusis (LASIK) model. Methods. Twelve albino rabbits had bilateral lamellar flaps created. Group A (eight eyes) was given gatifloxacin 0.3%; group B (eight eyes) was given ciprofloxacin 0.3%; and group C (eight eyes) served as the controls. Groups A and B received one drop of antibiotic 20 minutes before the creation of the lamellar flap, at the conclusion of flap formation, and four times per day for 3 days. All corneas were inoculated with 0.1 mL of 4 × 105 organisms/mL of S. pneumoniae immediately after flap formation. On day 3, all corneas were examined and cultured. Results. Group A (gatifloxacin) had no infiltrates and three areas of 1-mm central corneal haze. On day 3, one of eight corneas had a positive culture. Group B (ciprofloxacin) had seven infiltrates, including one perforation, and six of eight corneas had positive cultures. Group C (control) had eight corneal infiltrates, and all eight corneas had positive cultures. The data show a statistically significant difference between gatifloxacin and ciprofloxacin and gatifloxacin and control for mean infiltrate size and mean culture scores. Conclusions. The fourth-generation fluoroquinolone, topical gatifloxacin 0.3%, is superior to topical ciprofloxacin 0.3% for prophylaxis against a clinical isolate of S. pneumoniae in a rabbit LASIK model.