Nonsteroidal antiinflammatory drugs (NSAIDS) may be overused in cataract patients, and not enough eyecare specialists ask patients about their use of alternative medicines. These are findings from two studies presented at the recent annual meeting of the Canadian Ophthalmological Society.
The NSAIDs ketorolac and nepafenac are commonly used in patients who have undergone cataract surgery as a prophylactic measure to prevent macular edema, said David Almeida, MD, an Ophthalmology Resident at Queen’s University. But it turns out they should probably be reserved for patients who experience some sort of complication from their surgery or who have risk factors for macular
edema.
Dr. Almeida noted that it hasn’t been understood how much topical NSAIDs in cataract surgery actually affects rates of postoperative macular edema, whether one NSAID is superior to the other, or which patients benefit the most from post-surgery NSAIDs. He was co-author of a study that examined these points.
He won first prize for “Excellence in Ophthalmic Research” from the Canadian Ophthalmological Society (COS).
A prospective, placebo-controlled, double-masked randomized trial was performed in which 162 patients were dosed with drops for one month with either one of the two topical NSAIDs, or placebo, starting one day before surgery. A total of 54 patients were randomly placed into each of the four treatment groups.
Health-related quality-of-life metrics were determined with the Comparison of Ophthalmic Medications for Tolerability (COMTOL) questionnaire. Optical Coherence Tomography (OCT) measures were performed before surgery and again one month after.
At one month, it was found there was no statistically significant difference between the various OCT measures tested between the groups.
COMTOL questionnaire results showed no significant differences across the groups in terms of frequency of side-effects, or limitations to activities due to side-effects.
“Previous research has shown that for cataract patients with risk factors or complicated surgery, ketorolac works well at decreasing
macular edema,” Dr. Almeida said.
But in patients whose surgery is not complicated (such as with vitreous complications) and where no risk factors, such as retinal vascular disease, are present, the study showed there are no benefits from the NSAIDs, at least as shown by OCT findings.
Alternative medicine use Eyecare specialists need to ask glaucoma patients more about their use of alternative medicine. A study
of ophthalmologists across Canada found most either do not ask about alternative medicine use, nor discourage it. Findings were
presented by Dr. Tenley Bower from McGill University in Montreal.
Dr. Bower said it’s important to ask glaucoma patients about their use of alternative medicines because many can cause glaucoma or
interfere with their eye conditions.
In many cases, patients may use alternative therapies for their eye condition without the knowledge of their ophthalmologist.
A survey was performed on 241 ophthalmologists across Canada. It found a total of 26 per cent asked patients if they use alternative
treatments—respondents answered with “always”, “mostly”, or “sometimes”. The study found that those in practice for less than 20
years were significantly more likely to ask their patients about alternative medicine use than those in practice 20 years or more.
Most survey respondents, 62 per cent, said they do not discourage alternative medicine use, Dr. Bower said. However, younger
ophthalmologists who had fewer years of practice were significantly less likely to discourage alternative medicines than either older ophthalmologists or those with longstanding practices.
“When asked about whether or not alternative therapies affect patient compliance with traditional glaucoma therapies, 17 per cent said they did,” Dr. Bower noted. The researchers also found that ophthalmologists practicing in rural areas were significantly more likely to believe that compliance with prescribed medication was affected by alternative medicine use than those in urban areas or those in academic practices.
A total of 46 per cent of survey respondents indicated they believed that alternative medicines sometimes result in morbidity. On this note, those in practice less than 20 years were significantly less likely to believe alternative medicine use results in
morbidity than those in practice for 20 years or more.
Only nine per cent of respondents actually recommend the use of alternative medicines to glaucoma patients. If they did, those in practice less than 20 years were significantly more likely to recommend their use than those in practice at least 20 years.
Ginkgo biloba was the most commonly recommended alternative at 21 per cent followed by exercise, antioxidant vitamins and a healthy
diet. However, some studies suggest ginkgo can cause increased bleeding, others suggest a possible improvement in blood flow, and some suggest there is an interaction with blood thinner medications that could affect eye disease such as glaucoma or macular degeneration. Currently, there are no randomized control studies or other types of studies to prove the usefulness or harm of
complementary and alternative medicines for a patient’s glaucoma.
Dr. Cindy Hutnik, Associate Professor of Ophthalmology and Pathology, University of Western Ontario, was not involved in the study
but offered additional comments. She notes complementary and alternative medicines (CAMs) are somewhat like the generics in the pharmaceutical industry—there is no incentive to do good science on them because of poor financial returns.
A ‘real danger’ is that some patients believe alternative therapies are as good as, or better than, what their doctors suggest. Some may stop their prescribed therapy in favour of a herbal remedy or other treatment.
“You think patients are doing what you told them to do, but they’re not and unfortunately, the CAM industry is not regulated,” Dr. Hutnik said. “Communication with patients has to be more in depth because patients can really start going off on the wrong pathway.”
In a past survey, 14 per cent of Canadian glaucoma patients indicated they were currently using or had used alternative medicines for treatment of their eye disease. •