The physical trauma associated with cataract surgery includes

--disruption of the bloodaqueous barrier (BAB),

--an inflammatory response
--release of inflammatory mediators such as prostaglandins
and leukotrienes from arachidonic acid.
Curr Opin Ophthalmol , 2001;12:48.

The inflammatory response may lead to

--the activation of the immune cascade,
---involving neutrophils, macrophages, T lymphocytes and
additional inflammatory mediators.
J Cataract Refract Surg , 1996;22(Suppl. 1):7704

Post-cataract surgery inflammation presents as

--protein flare and inflammatory cells in the anterior chamber,
--hyperaemia,
--miosis,
--oedema,
--leukocyte migration,
--fibroblast proliferation and scar formation
Clin Ophthalmol, 2009;3:199210

Topical Non-steroidal Anti-inflammatory Drugs

NSAIDs are used before and after cataract surgery to prevent

and reduce inflammation
NSAIDs have demonstrated suppression of ocular inflammation
following
cataract and refractive surgery in patients.
NSAIDs control ocular pain and have similar activity against
inflammation compared with corticosteroids.
Surv Ophthalmol, 1992;36:25984 & Drugs ,2007;67:12911308

A retrospective review of 450 eyes reported no clinical pseudophakic

CME following uneventful phacoemulsification surgery in eyes
receiving prophylactic nepafenac compared to five eyes in the control
group.30 This result was statistically significant.
Inflammation 2000;24:357-370 & Ocul Pharmacol Ther 2008;24:392-398.

In subjects undergoing routine cataract surgery, and at low risk for

CME, the routine use of preoperative nepafenac may be all that is
necessary to achieve excellent visual recovery.
Eye (2010) 24, 9096.

Corticosteroid and NSAID effect on the inflammatory

cascade.
Clin Ophthalmol. 2009;3:219-226.

Potential complications of untreated post-operative inflammation

include pain, photophobia, posterior synechiae, pseudophakic
cellular precipitates, uveitis, elevated intraocular pressure (IOP)
and glaucoma.
Lancet , 2005;365:599609

Despite surgical advances, post-cataract surgery

inflammation is still a common cause of patient
discomfort, delayed recovery and reduced visual
outcome.
Ophthalmologica , 2003;217:40812

Clinical Trials Assessing Effectiveness of

Nepafenac

1.J Cataract Refract Surg. 2007;33:1546-1549

. Ophthalmol. 2009;3:219-226
2.Clin

All are carbon, but not

same

Topical NSAIDs may offer an advantage in the postoperative

setting as they effectively reduce pain and inflammation,
photophobia, intraocular pressure, pruritus, and
intraoperative miosis without the adverse effects that occur
with corticosteroids.

Eur Ophthal Rev 2012;6:173-7.

Although nepafenac is approved to treat postoperative

ocular inflammation and pain following cataract surgery, it
also has been used off-label to reduce pathologic ocular
angiogenesis, treat exudative age-related macular degeneration, prevent post pars-plana vitrectomy macular edema,
during epiretinal membrane surgery, and to maintain intraoperative mydriasis.4,7-11

TheAnnalsofPharmacotherapy

2013June,Volume47

Conventionsl
NSAIDs
All
ophthalmic
NSAID
preparations,
including
flurbiprofen,
diclofenac,
ketorolac, and bromfenac, were relatively
water-soluble
phenylalkanoic
and
phenylacetic
Due to theiracids.
inherent water solubility,
phenylalkanoic and phenylacetic acids it
would be predicted to have limited ability
to penetrate corneal epithelium.

Nepafenac,
amfenac, is
influences
penetration

an amide prodrug analog of

Less polar and therefore ionic
associated
with
faster
to corneal epithelium

Nepafenac
NSAID)

(Amide prodrug

Nepafenac 0.1% is a new ophthalmic NSAID and is the only one

with a prodrug structure, making it a neutral molecule.
This property, unlike the acidic nature of the other topical NSAIDs,
allows nepafenac to rapidly penetrate the cornea,
It is converted by intraocular hydrolases to its more active moiety
amfenac

Clin Ophthalmol. 2007 Dec; 1(4): 527533.

Nepafenac is unique, in that its bioconversion to amfenac is

targeted to the iris/ciliary body and, to an even greater extent,
the retina/choroid, suggesting nepafenac may have prolonged
activity in the vascularized tissues of the eye (Ke et al 2000).

Clin Ophthalmol. 2007 Dec; 1(4): 527533.

Postmarketing

experience with topical NSAIDs suggests

that patients with complicated ocular surgeries, corneal
denervation, corneal epithelial defects, diabetes mellitus, ocular
surface diseases (e.g. dry eye syndrome), rheumatoid arthritis
or repeat ocular surgeries within a short period of time may be
at increased risk for corneal adverse reactions which may
become sight threatening. Topical NSAIDs should be used with
caution in these patients.
Prolonged use of topical NSAIDs may increase patient risk for
occurrence and severity of corneal adverse reactions
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