Transcript Corneal Complications Following Topical Nonsteroidal Anti

Corneal Complications Following
Topical Nonsteroidal Anti-inflammatory
Drug Use
Martel, S., Akin M., Shih CY., Udell IJ
North Shore Long Island Jewish Health Systems
April 2010
The authors have no financial interest in the subject
matter of this presentation
Purpose and Background
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To examine the systemic and local risk factors
associated with corneal complications after topical
Non-Steroidal Anti-Inflammatory Drug (NSAID) use
To examine corneal complications after NSAID use
in a cohort of patients presenting subsequent to the
removal of generic diclofenac from the market
To our knowledge there is little data published
examining the systemic and local risk factors that
may predispose patients to corneal complications
after NSAID use
Methods
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This was a retrospective review of all patients
referred to the North Shore-Long Island Jewish
Health Systems for corneal complications
following topical NSAID use from 1998-2009
All cases were reviewed; any questionable
cases where factors besides NSAIDs use could
have contributed to complications were
eliminated
36 patients were included in the study
 23 of the 36 cases were subsequent to the
removal of diclofenac DSOS from the market
Results
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Mean age was 73
The mean duration of topical NSAID use was 60
days (range 6-360 days)
 29/36 patients used NSAID drops for >2
weeks
Average dosage used 4 times a day dosing
(range 1-8 drops a day)
Indications for NSAID use included postcataract surgery (79%) and dry eye (21%)
Table 1: Types of NSAID used
NSAID Type
Number of Patients
Nevanac ®
10
Acular ®
10
Xibrom ®
5
Diclofenac DSOS*
6
Voltaren ®
5
* Removed from the market 1999
Serologic Testing of Patients for Factors
Predisposing Patients to Corneal Melt
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Factors tested include: ANA, RF, SS-A,
SS-B, ESR
9 had positive blood work for
autoimmune factors, 6 negative. 21
patients still need to be tested
4/15 had known autoimmune disease,
5/15 reported no symptoms but had
positive bloodwork
Bromfenac: Post-Phaco 6 Weeks
Patient had history of periorbital radiation
2 wks after phacoemulsification
Patient treated for persistent epithelial defect
using NSAID’s for 1 month
•The patient had no rheumatologic symptoms, but +RF, +ANA, & elevated ESR
Bilateral descemetocele after 7 days of
QID Ketorolac preservative free
62 y.o. patient with “Dry Eye” (+ RF and + ANA)
Conclusion
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Corneal complications with NSAID use continue
to be seen despite the removal of generic
diclofenac from the market
Risks factors include: graft vs host disease,
radiation, pseudophakic bullous keratopathy, dry
eye symptoms related to autoimmune processes
Patients with Dry Eye Syndrome without clinically
manifesting autoimmune disease may be still be
predisposed to corneal melts if they have positive
serologic markers (ANA, RF, SS-A, SS-B)
Patients with risk factors should be monitored
frequently to prevent corneal complications and
to allow prompt discontinuation of the drug if
necessary