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NSAID — Topical Ophthalmic (COX-1 and COX-2 Inhibitor) Pregnancy: Avoid — NSAIDs in pregnancy risk premature ductus arteriosus closure from 20 weeks; minimal systemic absorption from topical but caution advised

Nepafenac 0.1% / 0.3% Eye Drops

Brand names: Nevanac 0.1%, Yellox 0.09%

Adult dose

Dose: 0.1%: 1 drop three times daily starting day before surgery, continuing day of surgery and for 2 weeks post-op; 0.3%: 1 drop once daily (prevention of macular oedema post-cataract)
Route: Topical (ophthalmic)
Frequency: Three times daily (0.1%); once daily (0.3%)
Max: 1 drop per dose
Prodrug — nepafenac is converted to amfenac (active metabolite) by intraocular hydrolases. Used for pain and inflammation post-cataract surgery, and prevention of macular oedema (CSME) in diabetic patients undergoing cataract surgery. Shake well before use.

Paediatric dose

Route: Topical
Frequency: Three times daily
Max: Same as adult
Licensed from age 2 years in some preparations; paediatric cataract surgery pain — specialist guidance

Dose adjustments

Renal

No adjustment — topical use

Hepatic

No adjustment

Clinical pearls

  • Prodrug advantage: nepafenac penetrates the corneal epithelium better than amfenac alone (lipophilic prodrug converted to amfenac by intraocular esterases) — achieving higher intraocular NSAID concentrations than direct amfenac administration
  • Cystoid macular oedema (CME) prevention: topical NSAIDs are as effective as topical steroids for routine CME prevention post-cataract surgery (NSAID vs steroid head-to-head trials); combination may provide additive benefit in high-risk patients (diabetics, post-uveitis)
  • Corneal melting warning: MHRA has received reports of serious corneal melt (keratolysis, perforation) with topical ophthalmic NSAIDs — highest risk in dry eye disease, rheumatoid arthritis with keratoconjunctivitis sicca, and repeated corneal surgeries; pre-assess ocular surface before prescribing
  • NSAID + steroid combination for post-cataract inflammation: many UK surgeons prescribe both (e.g., nepafenac TDS + dexamethasone QDS post-cataract) — based on evidence of additive efficacy and reduced steroid-related IOP elevation when NSAID permits lower steroid frequency
  • Diabetic macular oedema risk at cataract: diabetic patients have 3–4× higher risk of CME after cataract surgery — pre- and post-operative nepafenac 0.3% (Ilevro) once daily is specifically recommended in this population

Contraindications

  • Hypersensitivity to NSAIDs or aspirin
  • Contact lens wear during treatment
  • Active ocular surface disease (epithelial breakdown — NSAIDs delay corneal healing)

Side effects

  • Corneal epithelial toxicity — delays wound healing; stinging and burning
  • Corneal melting (keratolysis) — rare but serious; risk highest in dry eye, rheumatoid arthritis
  • Punctate keratitis
  • Increased bleeding time (reduced platelet aggregation)

Interactions

  • Other topical NSAIDs — additive corneal toxicity; do not combine
  • Topical corticosteroids — may reduce anti-inflammatory synergy (some protocols combine for maximum effect)

Monitoring

  • Corneal integrity — fluorescein staining at each visit
  • IOP
  • OCT — CME assessment at 4–6 weeks post-op
  • Symptom response

Reference: BNFc; BNF 90; MHRA NSAIDs Corneal Melting Warning; ESCRS Post-Cataract Inflammation Guidelines; SPC Nevanac. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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