Effect of preemptive topical diclofenac on postoperative pain relief after photorefractive keratectomy

Management of Pain after Photorefractive Keratectomy: A Report by the American Academy of Ophthalmology

OBJECTIVE

To evaluate current best practices for postoperative photorefractive keratectomy (PRK) pain control.

METHODS

Literature searches in the PubMed database were last conducted in October 2021 and were restricted to publications in English. This search identified 219 citations, of which 84 were reviewed in full text for their relevance to the scope of this assessment. Fifty-one articles met the criteria for inclusion; 16 studies were rated level I, 33 studies were rated level II, and 2 studies were rated level III.

RESULTS

Systemic opioid and nonsteroidal anti-inflammatory drugs (NSAIDs); topical NSAIDs; postoperative cold patches; bandage soft contact lenses (BCLs), notably senofilcon A contact lenses; and topical anesthetics were demonstrated to offer significantly better pain control than comparison treatments. Some other commonly reported pain mitigation interventions such as systemic gabapentinoids, chilled intraoperative balanced salt solution (BSS) irrigation, cycloplegia, and specific surface ablation technique strategies offered limited improvement in pain control over control treatments.

CONCLUSIONS

Systemic NSAIDs and opioid medications, topical NSAIDs, cold patches, BCLs, and topical anesthetics have been shown to provide improved pain control over alternative strategies and allow PRK-associated pain to be more tolerable for patients.

[Neuropathic pain in dry eye syndrome. Part 2. Clinical picture, diagnosis and treatment]

Burning eye syndrome is a chronic neuropathic pain syndrome, which is characterized by dysesthesia, spontaneous pain, allodynia and hyperalgesia. The review describes clinical features and presents available data on possible methods of diagnosis and therapy of this condition.

Bandage contact lens soaked in 0.1% diclofenac to relieve early postoperative pain and foreign body sensation after transepithelial photorefractive keratectomy

PURPOSE

To study the effects of a bandage contact lens immersed in 0.1% diclofenac on pain management for patients undergoing transepithelial photorefractive keratectomy (TPRK).

METHODS

In a prospective, comparative, contralateral, randomized, double-masked study, we assessed a total of 51 patients. The eyes of each patient were randomly divided into two groups. After TPRK, a normal soft bandage contact lens was placed on one eye as the control group, and a bandage contact lens soaked in diclofenac was placed on the other eye as the experimental group. When the bandage contact lens was not removed, postoperative pain and other ocular discomforts were compared at 2, 18, and 24 h and 2, 3, 4, and 5 postoperative days. Patients were then examined after 1 month. Visual acuity and subepithelial haze were also evaluated.

RESULTS

The mean pain score was 2.69 ± 1.96 in the control group, which was significantly higher than that in the experimental group, which received the diclofenac-soaked bandage contact lens at 2 postoperative hours. The statistical difference between the two groups' mean foreign body sensation at 2 postoperative hours was detected (p = 0.035). No differences were detected between the two groups' subepithelial haze scores or visual acuity.

CONCLUSION

A bandage contact lens soaked in 0.1% diclofenac solution can be used as a potential drug-delivery system to relieve early postoperative pain and foreign body sensation after TPRK.

Comparison of Postoperative Symptoms of Alcohol-Assisted Versus Mechanical Epithelial Removal in Photorefractive Keratectomy: A Contralateral Double Blind Clinical Trial

PURPOSE

To compare the short-term complaints of postoperative pain, and other ocular discomfort symptoms in patients who underwent photorefractive keratectomy (PRK) with alcohol-assisted epithelial removal in one eye versus mechanical debridement in the other eye.

METHOD

A prospective, interventional, contralateral double blind clinical trial was performed on 164 eyes of 82 candidates of PRK surgery. The patients were divided into two groups. The first group was alcohol-assisted PRK group in which the epithelial removal was performed on their right eye. The second group was mechanical PRK group in which epithelial removal was performed on their left eye. A numerical rating scale was given to the patients to describe the severity of postoperative pain on the first day following PRK. Postoperative discomfort symptoms including the complaints of light sensitivity, tearing, blurring, and foreign body sensation was also provided by the survey form.

RESULTS

One day following PRK, the mean pain score of the alcohol-assisted PRK group and the mechanical PRK group was 3.4±3.1 and 4.1±3.3, respectively (P=0.019). The highest scores recorded for alcohol-assisted and mechanical treated groups were burning (5.22) and light sensitivity (5.46), respectively. Sixty-eight (82.9%) of all patients experienced postoperative pain, and in 52 (76.5%) of them, the time of pain onset was less than 2 hrs.

CONCLUSION

We found less pain and discomfort using alcohol-assisted technique compared with mechanical epithelial removal that was provided by a detailed pain and ocular discomfort symptoms assessment one day following PRK surgery.

Update on Pain Management After Advanced Surface Ablation

PURPOSE

To provide an update for postoperative pain control strategies to help ophthalmic surgeons establish a more effective management plan for patients who underwent advanced surface ablation surgeries.

METHODS

Google Scholar, Scopus, ScienceDirect, and PubMed were the main resources used to search the medical literature.

RESULTS

The postoperative cornea's healing process is accompanied by intense pain as the chief complaint in the first days after the operation. Several strategies were developed to relieve postoperative pain after surface ablation procedures. These strategies included different preoperative, intraoperative, and postoperative methods. Considering the preoperative demographic and emotional factors, underlying dry eye, alternative epithelial removal techniques, bandage contact lenses, and topical or oral therapeutic agents are some examples of postoperative pain treatments after surface ablation procedures.

CONCLUSIONS

The current review revealed that despite the development of numerous protocols to relieve postoperative pain following surface ablations, the best approach could be a combination of different strategies. In practice, no validated and standardized strategy is available for total elimination of postoperative pain following advanced surface ablation surgeries. [J Refract Surg. 2021;37(11):782-790.].

Comparison of the effect of removing bandage contact lens on the days 3 and 5 following photorefractive keratectomy

AIM

To compare the outcomes of removing bandage contact lens (BCL) on days 3 and 5 after photorefractive keratectomy (PRK).

METHODS

One hundred patients who underwent PRK (a total of 200 eyes) were enrolled in the present study. The subjects were assigned to two groups. Group 1 consisted of the right eyes of subjects and bandage contact lenses removal were on the 3rd day; Group 2 consisted of the fellow eyes of same subjects and removed bandage contact lenses on the 5th day after PRK. Then, data obtained from both groups were compared. To evaluate complications, the subjects underwent a slit-lamp examination in all visits.

RESULTS

Filamentary keratitis was observed in one eye in both groups. The frequency of haze was higher in group 1; however, it was not significant between the two groups. Using mixed model analysis, significant differences were observed in the rate of complications as well as pain and eye discomfort scores between the groups (P < 0.05). No major complication was reported.

CONCLUSION

Majority of post-PRK corneal epithelial defect is healed on day 3. However, keeping BCL for 5 days postoperatively instead of the three days produces a slightly lower rate of total complication.

Use of topical bromfenac for treating ocular pain and inflammation beyond cataract surgery: a review of published studies

Topical ophthalmic nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat postoperative inflammation and pain following cataract surgery and for treatment and prophylaxis of pseudophakic cystoid macular edema (CME). Bromfenac is a brominated NSAID with strong in vitro anti-inflammatory potency. Like other ophthalmic NSAIDs, bromfenac is often used outside of the cataract surgery setting. This paper provides an overview of bromfenac’s preclinical ocular pharmacology and pharmacokinetics, followed by a review of 23 published clinical studies in which various marketed bromfenac formulations were used for conditions other than cataract surgery or pseudophakic CME. These include: post-refractive eye surgery; macular edema associated with diabetes, uveitis, or retinal vein occlusion; inflammation associated with age-related macular degeneration; pain related to intravitreal injections; and other ocular anterior segment and surface disorders with an inflammatory component. The published evidence reviewed supports the safety and effectiveness of bromfenac in these additional ophthalmic indications. Bromfenac was well tolerated when given alone or in combination with intravitreal anti-vascular endothelial growth factor agents, topical corticosteroids, or topical mast-cell stabilizers. The most common adverse event reported was ocular irritation. No serious adverse events (ie, corneal epithelial disorders) were reported, although the majority of studies did not systematically evaluate potential side effects. Corneal complications, such as melts reported with diclofenac and ketorolac, were not observed with bromfenac in the studies. In summary, published study data support the clinical utility of bromfenac in various ocular disorders beyond post-cataract surgery. Additional studies are warranted to further define the potential role of bromfenac ophthalmic solution in clinical practice.

Effects of Pranoprofen on Aqueous Humor Monocyte Chemoattractant Protein-1 Level and Pain Relief During Second-Eye Cataract Surgery

The aim of our present study is to evaluate the efficacy of pranoprofen eye drops as pain relief during sequential second-eye cataract surgery and to investigate the possible mechanism. Seventy-six patients scheduled for bilateral sequential cataract surgery were randomly assigned to two groups: (1) treatment group (administered pranoprofen eye drops), or (2) control group (administered artificial tears). Preoperative anxiety and intraoperative pain were assessed. Monocyte chemoattractant protein 1 (MCP-1) in the aqueous humor was measured with a suspension cytokine array. An extracapsular lens extraction model was established in the Wistar rat and the MCP-1 concentrations were measured with an enzyme-linked immunosorbent assay. We found that in the control group, the pain scores were significantly higher during second-eye surgery than during first-eye surgery (both scores P < 0.001). In the treatment group, there was no significant difference in the pain scores during first-eye and second-eye surgery (both scores P > 0.1). The pain during second-eye surgery was significantly lower in the treatment group than in the control group (both scores P < 0.01). And in the 1-week and 6-week interval subgroups, the pain scores during second-eye surgery were significantly lower in the treatment group than the control group (P = 0.047 and P = 0.035, respectively). While the second-eye MCP-1 level was significantly lower after a 1-week interval in the treatment group than in the control group (P = 0.012), but did not differ significantly after a 6-week interval (P > 0.1). A parallel trend in the MCP-1 concentration was detected in the rat model. In conclusion, the preoperative administration of pranoprofen eye drops reduced the perceived pain during second-eye cataract surgery, especially when performed after 1-week and 6-week intervals between the first-eye and second-eye surgery. MCP-1, a pain-related cytokine, was associated with the pain-relief mechanism of pranoprofen when second-eye surgery was performed 1 week after second-eye surgery.

Descemet membrane detachment in femtosecond laser-assisted cataract surgery: a case report

Background

Femtosecond laser-assisted cataract surgery (FLACS) has grown in popularity among ophthalmologists as a novel technique. However, descemet membrane detachment (DMD) began to be found as the complication after FLACS. We report a case of serious DMD following FLACS due to the inappropriate incision design.

Case presentation

An 85-year-old man with apparent cornea arcus senilis underwent femtosecond laser-assisted cataract surgery in his right eye. A biplanar model was chosen for the main incision. A serious descemet membrane detachment (DMD) occurred at the end of phacoemulsification, which was connected with the main incision. However, the surgeon confused it with the transient swelling of corneal endothelium, and did not treated DMD timely. DMD was confirmed by anterior segment optical coherence tomography (AS-OCT) at the postoperative 1-month follow-up. Eventually DMD was resolved by intracameral perfluropropane (C3F8) gas injection.

Conclusions

This case suggests that a careful incision separation and a triplanar incision design in FLACS may reduce the incidence of DMD in cataract surgery.

Comparison of analgesic effect of preoperative topical Diclofenac versus Ketorolac on postoperative pain after Corneal Collagen Cross Linkage

OBJECTIVE

To compare post-operative pain relieving effect of topical diclofenac 0.1% versus ketorolac 0.5% in Corneal Collagen Cross Linking (CXL) for patients diagnosed with keratoconus.

METHODS

This randomized controlled trial was carried out for six months from October 2016 to March 2017. We included young patients having keratoconus with k-readings greater than 47D and central corneal thickness more than 400 microns. All the patients received single dose one drop of topical diclofenac 0.1% to (Group-A) and ketorolac 0.5% to (Group-B) 30 minutes in advance of the corneal collagen cross linking (CXL) procedure. The CXL was performed with topical 0.1% riboflavin eye drops in 20% dextran as a photo sensitizer. After 36 hours of the CXL procedure, the postoperative intensity of pain was assessed verbally by patients with the help of visual analog scale (VAS) numbers from zero to five where 0 designated no pain & 5 symbolized worst pain.

RESULTS

The study comprised sixty eyes of forty one patients. Out of total 16 were male while 25 female patients. The mean age of the patients was 24.27 ± 2.93 years (range 20 to 29 years). In the conclusive analysis, diclofenac 0.1% was used on 30 patients in Group-A and ketorolac 0.5% on 30 subjects in Group-B. Pain relieving scores in Group-A (diclofenac 0.1%) was 2.57 ± 0.67 while in Group-B (ketorolac 0.4% treated arm) was 3.20 ± 0.61.

CONCLUSION

Topical diclofenac 0.1% is statistically comparable to topical ketorolac 0.5% in precluding severity of pain after corneal collagen cross linkage operation.

Efficacy and perioperative timing of bromfenac in the management of ocular discomfort after femtosecond laser-assisted laser in situ keratomileusis

PURPOSE

To evaluate the safety, efficacy, and appropriate perioperative timing of the use of topical bromfenac ophthalmic solution 0.07% after femtosecond laser-assisted laser in situ keratomileusis (LASIK).

SETTING

Keil LASIK Vision Center, Grand Rapids, Michigan, USA.

DESIGN

Prospective case series.

METHODS

Ocular discomfort was assessed 1, 2, and 5 hours postoperatively and the following morning using the Ocular Comfort Grading Assessment in patients treated with topical bromfenac 0.07% or artificial tears just before, just after, or before and after femtosecond laser-assisted LASIK. Visual outcomes and complications were noted up to 24 hours.

RESULTS

The study enrolled 64 patients (120 eyes). Patients who were treated with bromfenac 0.07% just before or before and after femtosecond laser-assisted LASIK showed the greatest statistically significant decrease in several discomfort scores within the first few hours in comparison with the control group. Two hours after surgery, the majority of patients who were treated before and after LASIK were sleeping comfortably. There were no significant differences in visual acuity; 1 day postoperatively, the uncorrected distance visual acuity was 20/20 in 106 eyes (89%) and 20/25 or better in 116 eyes (97%). At 3 months, all patients had binocular distance visual acuity of 20/20 or better and 86% of patients had 20/15 or better.

CONCLUSION

Ocular discomfort after femtosecond laser-assisted LASIK was reduced with a single dose of topical bromfenac 0.07% given immediately before surgery or given just before and after surgery and was typically minimal in all groups the morning after surgery.

Descemet membrane detachment during cataract surgery: etiology and management

PURPOSE OF REVIEW

The review updates the mechanisms, clinical presentations, diagnoses, and managements of Descemet membrane detachment during cataract surgery.

RECENT FINDINGS

The advent of new imaging techniques such as anterior segment optical coherence tomography and better comprehension of the clinical and pathological aspects of detachment have improved the diagnosis and treatment of this complication to the extent that the first algorithms and protocols have been proposed.

SUMMARY

Though infrequent, Descemet membrane detachment is a complication of intraocular surgery, including cataract surgery and phacoemulsification. Since the first systematic description and classification in the literature by Samuels in 1928 and its characterization as a potential sight-threatening condition by Scheie in 1964, plenty of retrospective and anecdotal evidence contribute to uncertainty and debate. The main controversy still lies in the choice between conservative treatment in hopes of spontaneaous reattachment and surgical treatment in a timely manner to maximize visual recovery.

Comparison of bandage contact lens removal on the fourth versus seventh postoperative day after photorefractive keratectomy: A randomized clinical trial

PURPOSE

To compare the outcomes of bandage contact lens (BCL) removal on the fourth versus seventh post-operative day following photorefractive keratectomy (PRK).

METHODS

This study recruited eyes of patients who underwent PRK surgery. The patients were randomly assigned to 2 groups. In Group 1 BCL was removed on the 4th postoperative day, while in Group 2, BCL was removed on the 7th postoperative day. After BCL removal, patients were asked to express their pain score and eye discomfort. At one and three months follow-up examinations, visual acuity scale was assessed. Slit-lamp examination was performed in all visits to evaluate complications.

RESULTS

260 eyes of 130 patients underwent PRK. The age and sex ratio were not significantly different between the two groups. One month after the surgery, the logMAR uncorrected distance visual acuity (UDVA) and corrected distance visual acuity (CDVA) were significantly lower in Group 2 (P value = 0.016, 0.001 respectively), however, the UDVA and CDVA were not significantly different after 3 months (P > 0.05). In Group 1, filamentary keratitis (FK) was observed in 10 (7.6%) eyes, 6 (4.61%) eyes were diagnosed with recurrent corneal erosion (RCE) and corneal haze was detected in 3 (2.3%) eyes. However, in Group 2, RCE was observed in 4 (2.3%) and FK was noted in 4 (3.07%) eyes. No haze was seen in Group 2. The difference in rate of complications was statistically significant (14.6% and 6.1% in Groups 1 and 2, respectively, P = 0.02). Pain and eye discomfort scores were not significantly different (P > 0.05). There was no major complications including infectious keratitis in either groups.

CONCLUSION

Following PRK surgery, BCL removal on the seventh postoperative day yields faster visual rehabilitation and lower rate of postoperative complications with no increase in eye pain, discomfort or infection.

Burning Eye Syndrome: Do Neuropathic Pain Mechanisms Underlie Chronic Dry Eye?

OBJECTIVE

Dry eye is a multi-factorial disorder that manifests with painful ocular symptoms and visual disturbances, which can only be partly attributed to tear dysfunction. This disorder may also involve neuroplasticity in response to neuronal injury. This review will emphasize the key characteristics of dry eye pain and its pathologic mechanisms, making the argument that a subset of dry eye represents a neuropathic pain disorder of the eye, more appropriately called "burning eye syndrome."

METHODS

A literature review was conducted using a PubMed search focusing on dry eye, corneal nociception, and neuropathic pain. Articles were reviewed and those discussing clinical course, pathophysiology, and neuronal regulation of chronic ocular pain as related to dry eye were summarized.

RESULTS

We found that there is a discordance between ocular pain and dryness on the ocular surface. Although tear dysfunction may be one of the initial insults, its persistence may be associated with repeated ocular sensory nerve injury leading to an acute-to-chronic pain transition associated with neuropathologic changes (peripheral and central sensitization), neuronal dysfunction, and spontaneous ocular pain.

CONCLUSION

Dry eye is becoming a major health concern due to its increasing incidence, significant morbidity, and economic burden. Recent evidence suggests that a subset of dry eye may be better represented as a chronic neuropathic pain disorder due to its features of dysesthesia, spontaneous pain, allodynia, and hyperalgesia. Future therapies targeted at the underlying neuroplasticity may yield improved efficacy for patients with this subset of dry eye, which we term "burning eye syndrome."

Analgesic effect of preoperative topical nonsteroidal antiinflammatory drugs on postoperative pain after laser-assisted subepithelial keratectomy

PURPOSE

To assess the effect of preoperative topical nonsteroidal antiinflammatory drugs (NSAIDs) on postoperative pain after laser-assisted subepithelial keratectomy (LASEK) and to investigate their mechanism.

SETTING

Severance Eye Hospital and Saeyan Eye Clinic, Seoul, South Korea.

DESIGN

Prospective randomized clinical trial.

METHODS

Participants in 2 related studies were assessed. Study 1 comprised patients scheduled for bilateral LASEK (Group 1) who were randomized to receive an NSAID in 1 eye and a placebo in the fellow eye 30, 20, and 10 minutes before LASEK. Postoperative pain, glare, tearing, and irritation were assessed using a visual analog scale. Study 2 comprised healthy subjects (Group 2) who were randomly divided into subgroups. The participants in these subgroups were randomized to receive ketorolac tromethamine 0.5% in 1 eye and placebo (ofloxacin 0.3%) in the fellow eye (Group 2A), proparacaine hydrochloride 0.5% in 1 eye and placebo in the fellow eye (Group 2B), or ketorolac tromethamine 0.5% in 1 eye and placebo in the fellow eye, followed 10 minutes later by 1 drop of proparacaine hydrochloride 0.5% in both eyes (Group 2C). In all 3 groups, corneal sensitivity was measured after 1, 2, and 6 hours.

RESULTS

The mean postoperative pain score in the NSAID-pretreated eye was statistically significantly lower than in the placebo-pretreated eye 6, 12, and 24 hours postoperatively (P < .05). The mean corneal sensitivity was statistically significantly lower in the NSAID-treated eye than in the placebo-treated eye at 1 and 2 hours in Groups 2A and 2C (P < .05).

CONCLUSION

Preoperative administration of topical NSAIDs before LASEK effectively reduces postoperative pain.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Efficacy and safety of pain relief medications after photorefractive keratectomy: review of prospective randomized trials

The objective of this review was to provide a comprehensive overview and comparison of results from all prospective randomized trials published to date of medications used to treat pain after photorefrative keratectomy (PRK). A PubMed database search revealed 23 prospective and randomized studies. They included the following classes of medications: nonsteroidal antiimflammatory drugs (NSAIDs), anesthetics, opiates, acetaminophen, gabapentin, and pregabalin. The studies found that although the efficacy of drugs tended to be similar, tetracaine 1% and nepafenac 0.1% tended to have the most analgesic effect. Delayed corneal reepithelialization was a common side effect of both topical anesthetics and topical NSAIDs. Tetracaine 1% resulted in the most significant delay in reepithelialization when tested against placebo control compared with other topical medications tested against placebo. Concomitant use of topical NSAIDs and topical anesthetics, especially tetracaine, may have to be avoided to minimize the risk for delayed corneal healing.

FINANCIAL DISCLOSURE

Neither author has a financial or proprietary interest in any material or method mentioned.