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ORIGINAL ARTICLE
Year : 1988  |  Volume : 36  |  Issue : 4  |  Page : 176-178

A comparative study of the effect of antiprostaglandins and steroids on aphakic cystoid macular oedema


34/9J-Medical Enclave, Rohtak - 124001, Haryana, India

Correspondence Address:
A K Khurana
34/9J-Medical Enclave, Rohtak - 124001, Haryana
India
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Source of Support: None, Conflict of Interest: None


PMID: 3075600

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  Abstract 

The present double masked, randomized and placebo control study was carried out to compare the effects of steroids and an antiprostaglandin drug on aphakic cystoid macular oedema (ACME) in 60 cases who underwent uneventful intracapsular lens extraction. These 60 eyes were equally divided into three groups depending on the type of prophylactic eye drop instilled viz. Placebo group (I), steroid group (11) and in­domethacin group (III). Angiographic incidence of ACME observed in groups I, II and III was 40%, 10% and I0%, respectively. It is concluded that prophylactic treatment with topical steroids or indomethacin have a definite role to play in reducing the incidence as well as severity of ACME. Hence, their use is recommended for the prophylaxis- of ACHE. However, to justify the superiority of indomethacin or dexamethasone over each other a large and long term compara­tive studs is suggested.

Keywords: ACME= Aphakic Cystoid Macular Oedema


How to cite this article:
Ahluwalia B K, Kalra S C, Parmar I, Khurana A K. A comparative study of the effect of antiprostaglandins and steroids on aphakic cystoid macular oedema. Indian J Ophthalmol 1988;36:176-8

How to cite this URL:
Ahluwalia B K, Kalra S C, Parmar I, Khurana A K. A comparative study of the effect of antiprostaglandins and steroids on aphakic cystoid macular oedema. Indian J Ophthalmol [serial online] 1988 [cited 2020 Aug 3];36:176-8. Available from: http://www.ijo.in/text.asp?1988/36/4/176/26124



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  Introduction Top


Aphakic cystoid macular oedema (ACME) has emerged as a major complication of modern cataract surgery. Since its recongnition as a distinct clinical entity by irvine [1], it has become the field of research of many workers. The reported incidence is so incon­sistent that it varies from 2-86% [1],[4]. Postulated aetiological factors include remote vitreous traction, hypotony, post-operative inflammation, aqueous biotoxic complexes and release of prostaglandins [1],[2],[5],[6],[7] In other words its incidence, aetiopathogen­sis, prevention and treatment still continue to be unsolved queries. The present investigations were therefore, carried out to report on the incidence of ACME in Indian subjects and also to evaluate the prophylactic role of topical steroids and a prostaglan­din synthetase inhibitor (indomethacin) , in this con­dition.


  Material & Methods Top


The present double masked placebo control study was carried out on 60 cases operated on for cataract. Patients with diseases predisposing to macular oedema such as diabetes mellitus, hypertension, glaucoma and history of allergies were excluded from the study. In all the cases intracapsular cataract extraction was done by the same surgeon using cryoprobe. Only those cases with no surgical accidents such as vitreous loss. rupture of the lens capsule, and severe postoperative iritis were selected.

The eye drops with code a, b and c were instilled 4 times a day on the day prior to surgery,- 3, 2 and 1 hours before surgery and were continued four times a day for 2 weeks after surgery in 20 patients each, randomly. Along with it 2% homatropine once a day and 1% chloromphenical eye drops three time a day were also instilled. Systemic antibiotic in the form of capsule chloramphenicol 250 mg four times a day was given in all the cases for 5 days. The patients were examined daily for a week and then on the 2nd, 3rd and 6th week. During each follow up visual acuity, slit lamp biomicroscopy, direct and indirect ophthalmoscopy and determination of in­traocular pressure by applanation tonometry were carried out. Flourescein angioraphy was performed on the 2nd and 6th postoperative week. All the observations were recorded on a proforma.

At the end of the study the code used for medication which was kept in a sealed envelope under lock and key by the senior author) was decoded and the cases were arranged in three groups of 250 cases each, depending upon the prophylactic eye drops used. Group I patients received placebo oil drops (code a). Group II - 1 % Dexamethasone eye drops (code b) and Group III, 1% Indomethacin eye drops (code c).

Grading of macular edema

The severity of cystoid macular edema was graded into 4 classes on the basis of fluorescein angiograms, slit lamp biomicroscopic appearancce, fundus picture and visual acuity as described by Miyake [8]. Brief remarks on the grading system is as follows:



Clinically significant cystoid macular edema was de­fined as a reduction in vision with full aphakic correc­tion, associated with ophthalmoscopically and biomic­roscopically visible cystoid. changes in the macula.


  Observations Top


The sixty patients included in this study comprised of 32 women and 28 men, the average age being 57 years (range 49-65). The incidence of cystoid macular edema observed in this study was higher in the placebo group (40%) as compared to the steroid group (10%) and the indomethacin group (10%). Out of the 8 cases from the placebo group who developed ACME, one had clinically significant macular oedema, while the other 7 had varying grades of angiographic macular oedema. [Table - 1], depicits the incidence and severity of ACME in different groups at the 2nd and 6th post-operative week. The comparative visual status of the three groups is shown in [Table - 2].


  Discussion Top


The therapy of established macular edema with oral prednisolone and indomethacin has been advocated by Gehring [9]; while on the other had Yannuzzi et al [10]sub and Stern et al [11] have given contradictory .reports. It is unlikely that patients with advanced aphakic cystoid macular oedema and foveal damage will regain better visual acuity, even if a therapoutic agent reduces the amount of macular edema. Thus, prophylaxis in the management of ACME is desirable. Klein et al [12] and Shriton et al [13] have used oral indomethacin for prophylaxis of ACME with contradic­tory reports. Furthermore, the side efects of oral indomethacin were significant and resulted in discon­tinuation of the medicine by many patients. Most of the recent studies advocate prophylatic use of topical indomethacin [8]. Therefore, an attempt was made in the present prospective double masked randomized, placebo control study to compare the effects of cor­ticosteroid and a prostaglandin'' synthetase inhibitor (Indomethacin) on the incidence and severity of ACME following uneventful cataract surgery.

It was observed that 2 (10%) cases each, out of 20, in which corticosteroid eye drops (0.1% De­xamethasone) and a prostaglandin synthetase inhibitor (I %, Indomethacin eye drops) were used as prophylac­tic treatment had angiographic macular edema. Out of the 20 case, which had peanut oil eye drops as placebo, 8 (40%) developed angiographical and 1 (5(%) had clinicaly significant edema. This incidence of ACME (5% clinically significant and 40% angiog­raphically visible macular edema) observed in the placebo group of this study is lower than western reports [3],[4]. This low incidence can be explained on the basis of rigid patient selection, as the patients with factors predisposing to macular edema such as diabetes mellitus, capsule rupture and severe post­operative iritis were excluded from this study. Racial factors and short duration of surgery under diffuse illumination may be other factors contributing to this low incidence.

In this study prophylactic treatment both with steroids as well as indomethacin eye drops, proved effective in reducing the incidence as well as severity of ACME when compared with the placebo group (p value /0.02 and /0.02). This observation has surmised that perhaps prostaglandins and allied factors do play a role in the production of macular edema as suggested by Miyake [7].

From our observations we have concluded that, though topical indomethacin has a definite role in reducing the incidence and severity of ACME, its superiority over steroids cannot be authenticated, as there are no eventual differences in visual acuity [Table - 2] and the incidence and severity of ACME [Table - 1] in patients pretreated with steroids and indomethacin. There fore, pre-treatment with such an agent is recom­mended. However, to justify the superiority of In­domethacin or Dexamethasone or their combination, a large and long term comparative study is suggested.

 
  References Top

1.
Irvine, R. Am. J. Ophthalmol 36:599. 1953.  Back to cited text no. 1
    
2.
Gass. J. DM and Norton EWD'frans. Am. Ophthalmol, Soc:64:232, 1966.   Back to cited text no. 2
    
3.
Meredith, TA. Kenyon, KR, Singerman. LJ and Fine SL Brit. J. Ophthalmol, 60:765, 1976.  Back to cited text no. 3
    
4.
Yammato, R. Jumera, Y. and Ozaki, R Jpn. J. Clinic. Ophthalmol, 33:267. 1979.  Back to cited text no. 4
    
5.
Delloporta, A. Amer. J. Ophthalmol. 40:781. 1955.  Back to cited text no. 5
    
6.
Worst, J CF Kim Montshed Augenheilked 167:376, 1978.  Back to cited text no. 6
    
7.
Miyake, K. Albrecht von Gralcs Ach. Kilon. Ophthalmol, 203:8, 1977.   Back to cited text no. 7
    
8.
Miyake. K. Jpn. J. Ophthalmol 22:80, 1978.   Back to cited text no. 8
    
9.
Gehring JR Arch. Ophthalmol 80:626, 1968.  Back to cited text no. 9
    
10.
Yannazzi LA, Klein, RM, Wallvn, RH, Cohen. N. and Katz, Amer. J. Ophtalmol. 84:517, 1971.  Back to cited text no. 10
    
11.
Stern, AL, Taylor, DM: Delburg, LA. and Consentino, RT 19 Ophthalmology, 88:942.  Back to cited text no. 11
    
12.
Klen, RM, Katzin. HM, and Yannuzzi, LA, Amer. J. Ophthalmol.87:497, 1979.  Back to cited text no. 12
    
13.
Sholiton, DB, Reinhart, WJ. Frank, KE. Amer. Intraocular implant Soc. J. 5(2):137, 1979.  Back to cited text no. 13
    



 
 
    Tables

  [Table - 1], [Table - 2]



 

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