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Algarni AM, Guyatt GH, Turner A, Alamri S. Antibiotic prophylaxis for corneal abrasion. Cochrane Database Syst Rev 2022; 5:CD014617. [PMID: 35622535 PMCID: PMC9139695 DOI: 10.1002/14651858.cd014617.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Corneal abrasion is a common disorder frequently faced by ophthalmologists, emergency physicians, and primary care physicians. Ocular antibiotics are one of the management options for corneal abrasion. A comprehensive summary and synthesis of the evidence on antibiotic prophylaxis in traumatic corneal abrasion is thus far unavailable, therefore we conducted this review to evaluate the current evidence regarding this important issue. OBJECTIVES To assess the safety and efficacy of topical antibiotic prophylaxis following corneal abrasion. Our objectives were 1) to investigate the incidence of infection with antibiotics versus placebo or alternative antibiotics in people with corneal abrasion; and 2) to investigate time to clinical cure, defined as complete healing (re-epithelialization) of the epithelium, with antibiotics versus placebo or alternative antibiotics in people with corneal abrasion. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register; 2021, Issue 4), Ovid MEDLINE, Embase.com, PubMed, the Latin American and Caribbean Health Sciences Literature database (LILACS), ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 25 April 2021. SELECTION CRITERIA We included randomized controlled trials (RCTs) comparing antibiotic with another antibiotic or placebo in children and adults with corneal abrasion due to any cause. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodology and assessed the certainty of the body of evidence for the prespecified outcomes using the GRADE classification. MAIN RESULTS Our search of the electronic databases yielded 8661 records. We screened 7690 titles and abstracts after removal of duplicates. We retrieved 32 full-text reports for further review. We included two studies that randomized a total of 527 eyes of 527 participants in the review. One study was conducted in Denmark, and one was conducted in India. The two studies did not examine most of our prespecified primary and secondary outcomes. The first study was a parallel-group RCT comparing chloramphenicol ocular ointment with fusidic acid ocular gels (frequency was not clearly reported). This study enrolled 153 participants older than 5 years of age with corneal abrasion in Denmark with a one-day follow-up duration. No participants had secondary infection in the fusidic acid group, whereas three (4.1%) participants in the chloramphenicol group had a slight reaction (risk ratio [RR] 0.15, 95% confidence interval [CI] 0.01 to 2.79; 144 participants; very low certainty evidence). Thirty-one (44.3%) participants in the fusidic acid arm and 34 (46.6%) participants in the chloramphenicol arm were cured (defined as the area of abrasion zero and no infection) at day 1 (RR 0.94, 95% CI 0.65 to 1.34; 144 participants; very low certainty evidence). Without providing specific data, the study reported that the degree of pain was not affected by the interventions received. The most common adverse events reported were itching and discomfort of the eye, which occurred in approximately one-third of participants in each group (low certainty evidence). A second multicenter, two-arm RCT conducted in India enrolled 374 participants older than 5 years of age with corneal abrasion who presented within 48 hours after injury. This study investigated the effect of a three-day course of either ocular ointment combinations of chloramphenicol-clotrimazole or chloramphenicol-placebo (all three times daily). At day 3, 169 (100%) participants in the chloramphenicol-clotrimazole arm and 203 (99%) out of 205 participants in the chloramphenicol-placebo arm were cured without any complication, defined as complete epithelialization of the cornea without evidence of infection (RR 1.01, 95% CI 0.99 to 1.03; 374 participants; very low certainty evidence). Four participants assigned to the chloramphenicol-placebo arm experienced mild adverse events: two participants (1%) had mild chemosis and irritation, and two (1%) had small single sterile corneal infiltrates (low certainty evidence). AUTHORS' CONCLUSIONS Given the low to very low certainty of the available evidence, any beneficial effects of antibiotic prophylaxis in preventing ocular infection or accelerating epithelial healing following a corneal abrasion remain unclear. Moreover, the current evidence is insufficient to support any antibiotic regimen being superior to another. There is a need for a well-designed RCT assessing the efficacy and safety of ocular antibiotics in the treatment of corneal abrasion with a particular focus on high-risk populations and formulation of interventions.
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Affiliation(s)
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | | | - Saad Alamri
- Department of public health, General Directorate of Health Affairs Aseer Region, Abha, Saudi Arabia
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Yu CW, Kirubarajan A, Yau M, Armstrong D, Johnson DE. Topical pain control for corneal abrasions: A systematic review and meta-analysis. Acad Emerg Med 2021; 28:890-908. [PMID: 33508879 DOI: 10.1111/acem.14222] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/21/2021] [Accepted: 01/23/2021] [Indexed: 01/12/2023]
Abstract
OBJECTIVES Corneal abrasions are common ophthalmic presentations to emergency departments. Among emergency physicians and ophthalmologists, there are highly variable practice patterns with regard to management of resultant pain and discomfort. The goal of this study was to review and analyze the efficacy and safety of topical pain therapies for corneal abrasions, including topical anesthetics, nonsteroidal anti-inflammatory drugs (NSAIDs), cycloplegics, steroids, pressure patching, and the use of a bandage contact lens (BCL). METHODS The review followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. The protocol was established a priori and published on PROSPERO (CRD42020201288). MEDLINE, EMBASE, CENTRAL, and Web of Science were searched until December 31, 2020. Primary studies comparing topical pain therapies to another therapy or control were included. Primary outcomes included percentage of corneal abrasions healed at 24, 48, and 72 hours, as well as pain control at 24 and 48 hours. Secondary outcomes included use of oral analgesia and incidence of complications. Risk of bias was assessed using validated tools. Quality of evidence was assessed using the GRADE methodology. RESULTS Overall, 33 studies (31 randomized controlled trials [RCTs], two cohort studies) comprising 4,167 patients with corneal abrasions were analyzed. Only the data for topical NSAIDs were of adequate evidence from which to draw conclusions; topical NSAIDs demonstrated significantly reduced pain scores at 24 hours (standardized mean differences [SMD] -0.69, 95% CI = -0.98 to -0.41) and 48 hours (SMD = -0.56, 95% CI = -1.02 to -0.10) as well as 53% (95% CI = 34% to 67%) lower oral analgesia use compared to control. Based on available data, topical anesthetics, cycloplegics, patching, and the use of a BCL did not result in any significant difference in pain scores or use of oral analgesia, while no studies examined topical steroids. No interventions resulted in healing delays or significantly higher rates of complications compared to controls. CONCLUSIONS There was strong evidence to support that topical NSAIDs reduce pain associated with corneal abrasions in the first 48 hours and the need for oral analgesia. The existing evidence was insufficient to support or refute the use of topical anesthetics, cycloplegics, steroids, or BCL for pain control in corneal abrasions. Pressure patching was ineffective at pain reduction and may increase the risk of complications. Delays in healing or other complications were not significantly different between any intervention or control for simple, uncomplicated corneal abrasions; however, larger RCTs are required to identify any differences in rare complications.
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Affiliation(s)
- Caberry W. Yu
- Faculty of Medicine Queen’s University Kingston Ontario Canada
| | | | - Matthew Yau
- Faculty of Medicine University of Toronto Toronto Ontario Canada
| | - Dawn Armstrong
- Faculty of Medicine Queen’s University Kingston Ontario Canada
| | - Davin E. Johnson
- Department of Ophthalmology Kingston Health Sciences CentreQueen’s University Kingston Ontario Canada
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Ayyildiz T, Ozturk Y. INVESTIGATING THE FACTORS THAT AFFECT THE FREQUENCY OF VISITS DUE TO CORNEAL FOREIGN BODIES. SANAMED 2020. [DOI: 10.24125/sanamed.v15i2.411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Wakai A, Lawrenson JG, Lawrenson AL, Wang Y, Brown MD, Quirke M, Ghandour O, McCormick R, Walsh CD, Amayem A, Lang E, Harrison N. Topical non-steroidal anti-inflammatory drugs for analgesia in traumatic corneal abrasions. Cochrane Database Syst Rev 2017; 5:CD009781. [PMID: 28516471 PMCID: PMC6481688 DOI: 10.1002/14651858.cd009781.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Traumatic corneal abrasions are relatively common and there is a lack of consensus about analgesia in their management. It is therefore important to document the clinical efficacy and safety profile of topical ophthalmic non-steroidal anti-inflammatory drugs (NSAIDs) in the management of traumatic corneal abrasions. OBJECTIVES To identify and evaluate all randomised controlled trials (RCTs) comparing the use of topical NSAIDs with placebo or any alternative analgesic interventions in adults with traumatic corneal abrasions (including corneal abrasions arising from foreign body removal), to reduce pain, and its effects on healing time. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2017, Issue 2), MEDLINE Ovid (1946 to 30 March 2017), Embase Ovid (1947 to 30 March 2017), LILACS (Latin American and Caribbean Health Sciences Literature Database) (1982 to 30 March 2017), OpenGrey (System for Information on Grey Literature in Europe) (www.opengrey.eu/); searched 30 March 2017, ZETOC (1993 to 30 March 2017), the ISRCTN registry (www.isrctn.com/editAdvancedSearch); searched 30 March 2017, ClinicalTrials.gov (www.clinicaltrials.gov); searched 30 March 2017 and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en); searched 30 March 2017. We did not use any date or language restrictions in the electronic searches for trials.We checked the reference lists of identified trials to search for further potentially relevant studies. SELECTION CRITERIA RCTs comparing topical NSAIDs to placebo or any alternative analgesic interventions in adults with traumatic corneal abrasions. DATA COLLECTION AND ANALYSIS Two review authors independently performed data extraction and assessed risks of bias in the included studies. We rated the certainty of the evidence using GRADE. MAIN RESULTS We included nine studies that met the inclusion criteria, reporting data on 637 participants.The studies took place in the UK, USA, Israel, Italy, France and Portugal. These studies compared five types of topical NSAIDs (0.1% indomethacin, 0.03% flurbiprofen, 0.5% ketorolac, 1% indomethacin, 0.1% diclofenac) to control (consisting of standard care and in four studies used placebo eye drops). Overall, the studies were at an unclear or high risk of bias (particularly selection and reporting bias). None of the included studies reported the primary outcome measures of this review, namely participant-reported pain intensity reduction of 30% or more or 50% or more at 24 hours. Four trials, that included data on 481 participants receiving NSAIDs or control (placebo/standard care), reported on the use of 'rescue' analgesia at 24 hours as a proxy measure of pain control. Topical NSAIDs were associated with a reduction in the need for oral analgesia compared with control (risk ratio (RR) 0.46, 95% confidence interval (CI) 0.34 to 0.61; low-certainty evidence). Approximately 4 out of 10 people in the control group used rescue analgesia at 24 hours. No data were available on the use of analgesia at 48 or 72 hours.One trial (28 participants) reported on the proportion of abrasions healed after 24 and 48 hours. These outcomes were similar in both arms of the trial. (at 24 hours RR 1.00 (0.81 to 1.23); at 48 hours RR 1.00 (0.88 to 1.14); low-certainty evidence). In the control group nine out of 10 abrasions were healed within 24 hours and all were healed by 48 hours. Complications of corneal abrasions were reported in 6 studies (609 participants) and were infrequently reported (4 complications, 1 in NSAID groups (recurrent corneal erosion) and 3 in control groups (2 recurrent corneal erosions and 1 corneal abscess), very low-certainty evidence). Possible drug-related adverse events (AEs) were reported in two trials (163 participants), with the number of adverse events low (4 AEs, 3 in NSAID group, including discomfort/photophobia on instillation, conjunctival hyperaemia and urticaria, and 1 in the control group, corneal abscess) very low-certainty evidence. AUTHORS' CONCLUSIONS The findings of the included studies do not provide strong evidence to support the use of topical NSAIDs in traumatic corneal abrasions. This is important, since NSAIDs are associated with a higher cost compared to oral analgesics. None of the trials addressed our primary outcome measure of participant-reported pain intensity reduction of 30% or more or 50% or more at 24 hours.
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Affiliation(s)
- Abel Wakai
- Division of Population Health Sciences (PHS), Royal College of Surgeons in Ireland (RCSI)Emergency Care Research Unit (ECRU)123 St. Stephen's GreenDublin 2Ireland
| | - John G Lawrenson
- City University of LondonApplied Vision Research Centre, School of Health SciencesNorthampton SquareLondonUKEC1V 0HB
| | - Annali L Lawrenson
- Epsom General HospitalEmergency DepartmentDorking RoadEpsomSurreyUKKT18 7EG
| | - Yongjun Wang
- Schulich School of Medicine & Dentistry, Western UniversityKresge Building, Rm. K1LondonONCanada
| | - Michael D Brown
- Michigan State University College of Human MedicineDepartment of Emergency Medicine100 Michigan NEGrand RapidsMIUSA49503
| | - Michael Quirke
- Division of Population Health Sciences (PHS), Royal College of Surgeons in Ireland (RCSI)Emergency Care Research Unit (ECRU)123 St. Stephen's GreenDublin 2Ireland
| | - Omar Ghandour
- Royal College of Surgeons in Ireland (RCSI)School of Medicine123 St. Stephen's GreenDublin 2Ireland
| | - Ryan McCormick
- Royal College of Surgeons in Ireland (RCSI)School of Medicine123 St. Stephen's GreenDublin 2Ireland
| | - Cathal D Walsh
- Department of Mathematics and StatisticsHealth Research Institute (HRI) and MACSIUniversity of LimerickIreland
| | - Ahmed Amayem
- University of CalgaryCumming School of MedicineCalgaryAlbertaCanada
| | - Eddy Lang
- University of CalgaryDepartment of Emergency Medicine2015 42 Ave SWCalgaryAlbertaCanadaT2T 2M8
| | - Nick Harrison
- Beaumont HospitalBeaumont Health Emergency Medicine ResidencyRoyal OakMichiganUSA48067
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Dorbandt DM, Labelle AL, Mitchell MA, Hamor RE. The effects of topical diclofenac, topical flurbiprofen, and humidity on corneal sensitivity in normal dogs. Vet Ophthalmol 2016; 20:160-170. [DOI: 10.1111/vop.12386] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 03/22/2016] [Accepted: 04/06/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Daniel M. Dorbandt
- Department of Veterinary Clinical Medicine; College of Veterinary Medicine; University of Illinois Urbana-Champaign; 1008 W. Hazelwood Drive Urbana IL 61802 USA
| | - Amber L. Labelle
- Department of Veterinary Clinical Medicine; College of Veterinary Medicine; University of Illinois Urbana-Champaign; 1008 W. Hazelwood Drive Urbana IL 61802 USA
| | - Mark A. Mitchell
- Department of Veterinary Clinical Medicine; College of Veterinary Medicine; University of Illinois Urbana-Champaign; 1008 W. Hazelwood Drive Urbana IL 61802 USA
| | - Ralph E. Hamor
- Department of Veterinary Clinical Medicine; College of Veterinary Medicine; University of Illinois Urbana-Champaign; 1008 W. Hazelwood Drive Urbana IL 61802 USA
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Calder L, Balasubramanian S, Stiell I. Lack of consensus on corneal abrasion management: results of a national survey. CAN J EMERG MED 2015; 6:402-7. [PMID: 17378958 DOI: 10.1017/s1481803500009398] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ABSTRACT:Objectives:Our objective was to determine the practice patterns of Canadian emergency physicians with respect to the management of traumatic corneal abrasions.Methods:After developing our instrument and pilot testing it on a sample of emergency residents, we randomly surveyed 470 members of the Canadian Association of Emergency Physicians, using a modified Dillman technique. We distributed a pre-notification letter, an 18-item survey, and appropriate follow-up surveys to non-responders. Those members with an email address (n= 400) received a Web-based survey, and those without (n= 70) received a survey by post. The survey focused on the indications and utilization of analgesics (oral and topical), cycloplegics, eye patches and topical antibiotics.Results:Our response rate was 64% (301/470), and the median age of respondents was 38 years. Most (77.7%) were male, 71.8% were full-time emergency physicians, 76.5% were emergency medicine certified, and 64.4% practised in teaching hospitals. Pain management preferences (offered usually or always) included oral analgesics (82.1%), cycloplegics (65.1%) and topical nonsteroidal anti-inflammatory drugs (NSAIDs) (52.8%). Only 21.6% of respondents performed patching, and most (71.2%) prescribed topical antibiotics, particularly for contact lens wearers and patients with ocular foreign bodies. Two-thirds of the respondents provided tetanus toxoid if a foreign body was present, and 46.2% did so even if a foreign body was not present. Most respondents (88.0%) routinely arranged follow-up.Conclusions:This national survey of emergency physicians demonstrates a lack of consensus on the management of traumatic corneal abrasions. Further study is indicated to determine the optimal treatment, particularly regarding the use of topical NSAIDs.
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Affiliation(s)
- Lisa Calder
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada.
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Abstract
PURPOSE To describe the result of using a polyethylene glycol hydrogel contact lens (ReSure; Ocular Therapeutix, Inc, Bedford, MA) as a protective bandage over denuded areas of Tenons after pterygium removal. METHODS Five sequential patients underwent pterygium removal with a conjunctival autograft and painting of bare Tenons in the area of the graft retrieval with a biodegradable polymer, and these patients were followed for 1 year for immediate postoperative pain, epithelial healing, and long-term conjunctival scarring. RESULTS All patients showed prolonged persistence of the polymer for up to 8 to 10 weeks with resultant increased conjunctival inflammation and scarring with no evidence of decreased postoperative pain. CONCLUSIONS This hydrogel polymer seems to cause prolonged inflammation and resultant scarring when used over extended areas of Tenons, and it has no role in reducing pain after pterygium surgery.
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Maldonado RM, Vianna RNG, Cardoso GP, de Magalhães AV, Burnier MN. Intravitreal injection of commercially available ketorolac tromethamine in eyes with diabetic macular edema refractory to laser photocoagulation. Curr Eye Res 2011; 36:768-73. [PMID: 21780926 DOI: 10.3109/02713683.2011.585734] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To evaluate the short-term effect of a single intravitreal injection of commercially available ketorolac tromethamine (KT) in eyes with diabetic macular edema refractory to laser photocoagulation. METHODS Prospective interventional case series. Twenty five patients with diabetic macular edema refractory to laser photocoagulation received a single intravitreal injection of commercially available KT (Toradol®), in a dose of 3000 µg. Examination included assessment of ETDRS-best corrected visual acuity (BCVA), measurement of intraocular pressure and high resolution imaging by optical coherence tomography, preoperatively and 7, 15, and 30 days postoperatively. RESULTS In the follow up visits at 7, 15 and 30 days, BCVA had improved five or more letters in 20% (95% confidence interval, 7.7-38.9%), 16% (95% confidence interval, 5.3-34.2%) and 28% (95% confidence interval, 13.2-47.7%) respectively. An improvement in macular thickness was also observed, although it has not been statistically significant. CONCLUSION This pilot study showed that a single intravitreal injection of 3000 µg of commercial KT led to a short-term improvement of visual acuity in approximately 30% of eyes with diabetic macular edema refractory to laser photocoagulation.
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Affiliation(s)
- Renata Malvezzi Maldonado
- Retina & Vitreous Unit, Department of Ophthalmology, Fluminense Federal University, Niterói, Rio de Janeiro, Brazil
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Wang XJ, Wong SH, Givergis R, Chynn EW. Evaluation of analgesic efficacy of bromfenac sodium ophthalmic solution 0.09% versus ketorolac tromethamine ophthalmic solution 0.5% following LASEK or Epi-LASIK. Clin Ophthalmol 2011; 5:1451-7. [PMID: 22034570 PMCID: PMC3198424 DOI: 10.2147/opth.s24656] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background To evaluate the analgesic efficacy of bromfenac sodium ophthalmic solution 0.09% compared with ketorolac tromethamine ophthalmic solution 0.5% in laser epithelial keratomileusis (LASEK) or epithelial keratomileusis (epi-LASEK), sometimes referred to as epi-LASIK. Methods Eighty eyes (from 40 patients, 18 men and 22 women) undergoing bilateral simultaneous LASEK or epi-LASEK were randomized to receive ketorolac in one eye and bromfenac in the other. Mean age was 33.13 ± 9.34 years. One drop of bromfenac or ketorolac was instilled in each eye 15 minutes and one minute prior to surgery, and two and four hours following surgery. Patients were instructed to instill the medications on-label each day through postoperative day 4. The subjects completed pain and visual blurriness assessments from day of surgery to postoperative day 4. Uncorrected visual acuity was tested on postoperative days 1 and 6. Results For each of the five days, pain scores for bromfenac-treated eyes were significantly less than that for ketorolac-treated eyes (P < 0.01). Of the 40 patients, 32 (80%) said bromfenac provided better postoperative analgesia than ketorolac. There was no statistically significant difference in visual blurriness scores between the two groups (P > 0.1). Uncorrected visual acuity did not vary significantly between the treatment groups (P > 0.1). No serious adverse events were noted. Conclusion Bromfenac is subjectively superior to ketorolac in reducing postoperative pain following LASEK or epi-LASEK. The subjects tolerated the drugs well with no serious adverse outcomes and no difference in uncorrected visual acuity.
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Toris CB, Gulati V. The biology, pathology and therapeutic use of prostaglandins in the eye. ACTA ACUST UNITED AC 2011. [DOI: 10.2217/clp.11.42] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Ting JYS, Barns KJ, Holmes JL. Management of Ocular Trauma in Emergency (MOTE) Trial: A pilot randomized double-blinded trial comparing topical amethocaine with saline in the outpatient management of corneal trauma. J Emerg Trauma Shock 2011; 2:10-4. [PMID: 19561949 PMCID: PMC2700573 DOI: 10.4103/0974-2700.44676] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2008] [Accepted: 09/01/2008] [Indexed: 12/05/2022] Open
Abstract
Background: It is unclear whether local anesthetic eye drops can be safely used for the topical anesthesia of patients with minor corneal injury who are discharged from the emergency department (ED). Objectives: To assess whether topical 0.4% amethocaine self-administered to a maximum recommended frequency of once every hour for 36–48 h is safe in the management of uncomplicated corneal injury in patients discharged from the ED. Patients and Methods: A pilot randomized double-blinded trial comparing topical 0.4% amethocaine with topical normal saline. Results: Forty-seven subjects were recruited, with 22 randomized to receive amethocaine and 25 to receive placebo (normal saline). Baseline characteristics, including corneal injury type, were similar in both groups. There were no significant functional or clinical adverse sequelae in the majority of enrolled patients who could be contacted at 2 weeks (17/22 for amethocaine and 21/25 for placebo). Follow-up for the primary study outcome was suboptimal, with only 7/22 from the amethocaine group and 9/25 from the saline group presenting for 36–48 h review; there was a statistically nonsignificant trend for persistence of the corneal defect in the amethocaine group as compared with the saline group (2/7 and 1/9, respectively). Conclusion: Compared with saline drops, amethocaine eye drops are not definitely safe but they are effective for topical analgesia in minor corneal injury. Until further definitive studies, topical nonsteroidal agents or long-lasting artificial tears may be preferred for the topical analgesia of minor corneal injury. Return for corneal re-evaluation will necessarily remain suboptimal in an otherwise self-limiting condition, leading to a bias even if study recruitment is good.
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Affiliation(s)
- Joseph Y S Ting
- Department of Emergency Medicine, Mater Adults' Hospital, Raymond TCE, South Brisbane, 4101 Qld, Australia
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Abstract
Eye injuries come at a high cost to society and are avoidable. Ocular blast injuries can be primary, from the blast wave itself; secondary, from fragments carried by the blast wind; tertiary; due to structural collapse or being thrown against a fixed object; or quaternary, from burns and indirect injuries. Ballistic eye protection significantly reduces the incidence of eye injuries and should be encouraged from an early stage in Military training. Management of an injured eye requires meticulous history taking, evaluation of vision that measures the acuity and if there is a relative pupillary defect as well as careful inspection of the eyes, under anaesthetic if necessary. A lateral canthotomy with cantholysis should be performed immediately if there is a sight-threatening retrobulbar haemorrhage. Systemic antibiotics should be prescribed if there is a suspected penetrating or perforating injury. A ruptured globe should be protected by an eye shield. Primary repair of ruptured globes should be performed in a timely fashion. Secondary procedures will often be required at a later date to achieve sight preservation. A poor initial visual acuity is not a guarantee of a poor final result. The final result can be predicted after approximately 3-4 weeks. Future research in eye injuries attempts to reduce scarring and neuronal damage as well as to promote photoreceptor rescue, using post-transcriptional inhibition of cell death pathways and vaccination to promote neural recovery. Where the sight has been lost sensory substitution of a picture from a spectacle mounted video camera to the touch receptors of the tongue can be used to achieve appreciation of the outside world.
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Affiliation(s)
- Robert Scott
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
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Kim SJ, Flach AJ, Jampol LM. Nonsteroidal anti-inflammatory drugs in ophthalmology. Surv Ophthalmol 2010; 55:108-33. [PMID: 20159228 DOI: 10.1016/j.survophthal.2009.07.005] [Citation(s) in RCA: 240] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2009] [Revised: 07/20/2009] [Accepted: 07/28/2009] [Indexed: 02/02/2023]
Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) are increasingly employed in ophthalmology to reduce miosis and inflammation, manage scleritis, and prevent and treat cystoid macular edema associated with cataract surgery. In addition, they may decrease postoperative pain and photophobia associated with refractive surgery and may reduce the itching associated with allergic conjunctivitis. In recent years, the U.S. Food and Drug Administration has approved new topical NSAIDs, and previously approved NSAIDs have been reformulated. These additions and changes result in different pharmacokinetics and dosing intervals, which may offer therapeutic advantages. For example, therapeutic effects on diabetic retinopathy and age-related macular degeneration may now be achievable. We provide an updated review on NSAIDs and a summary of their current uses in ophthalmology with attention to potential future applications.
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Affiliation(s)
- Stephen J Kim
- Department of Ophthalmology, Vanderbilt University, Nashville, Tennessee 37232, USA.
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Bandage Contact Lens and Topical Indomethacin for Treating Persistent Corneal Epithelial Defects After Vitreoretinal Surgery. Cornea 2007; 26:1178-81. [DOI: 10.1097/ico.0b013e318151f811] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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15
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Abstract
Recent advances in cataract surgery, such as phacoemulsification, small-incision surgery and advances in foldable intraocular lenses, have resulted in the decrease of physical trauma associated with cataract surgery. The decrease in the physical surgical trauma decreases the release of prostaglandins, which are the main players in postoperative ocular inflammation. However, postoperative inflammation continues to be a cause of patient discomfort, delayed recovery and, in some cases, suboptimal visual results. Left untreated, this inflammation might interfere with patients' rehabilitation and/or contribute to the development of other complications, such as cystoid macular oedema.NSAIDs are commercially available, in topical or systemic formulations, for the prophylaxis and treatment of ocular conditions. Topically applied NSAIDs are commonly used in the management and prevention of non-infectious ocular inflammation and cystoid macular oedema following cataract surgery. They are also used in the management of pain following refractive surgery and in the treatment of allergic conjunctivitis. Despite their chemical heterogeneity, all NSAIDs share the similar therapeutic property of inhibiting the cyclo-oxygenase enzyme. The appeal of using NSAIDs in the treatment of ocular inflammation hinges on the complications associated with corticosteroids, the other commonly used therapy for ophthalmic inflammation.
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Affiliation(s)
- Joseph Colin
- University Hospital Complex of Bordeaux, Peflegrin Hospital, Bordeaux, France.
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Aslam SA, Sheth HG, Vaughan AJ. Emergency management of corneal injuries. Injury 2007; 38:594-7. [PMID: 16949077 DOI: 10.1016/j.injury.2006.04.122] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2006] [Revised: 03/28/2006] [Accepted: 04/11/2006] [Indexed: 02/02/2023]
Abstract
UNLABELLED Corneal injuries account for a significant proportion of the ophthalmic workload of most emergency departments. Although the vast majority of cases are relatively minor, accurate diagnosis and appropriate management are vital to prevent potentially sight-threatening sequelae. We present a survey of corneal injury cases at a general emergency department. INTRODUCTION Corneal injuries are very common in both the adult and paediatric population and account for a significant proportion of the workload of most emergency departments. This survey assesses management of corneal injury cases at a general emergency department. MATERIALS AND METHODS A retrospective case study was performed of 100 patients consecutively diagnosed with a corneal abrasion by slit lamp examination at the emergency department of the Chelsea and Westminster Hospital, London. Each case was assessed to determine documentation of set criteria including visual acuity (VA), treatment and grade of examiner. RESULTS The commonest cause of injury was direct minor trauma (64% of cases) with contact lens related problems accounting for 12% of presentations. VA was documented correctly in 85 adult patients (90.4% of adults), incorrectly in 2 cases, and not documented at all in 7 adults (7.4%). VA was not recorded in paediatric cases. All cases were treated with topical chloramphenicol drops although frequency of treatment ranged from 2 to 5 times daily and duration of treatment ranged between 3 and 5 days and for 7 days. 6 cases (6%) were assessed by an emergency nurse practitioner and the remaining number were seen by a casualty officer. DISCUSSION VA must be accurately documented in all adult cases and should be documented in children of school age. A pinhole test should be performed in cases where VA is below 6/9. For analgesia, the use of topical nonsteroidal anti-inflammatory drugs, lubricants and bandage contact lens should be considered. Emergency nurse practitioners and general practitioners are ideally placed to follow-up uncomplicated cases.
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Affiliation(s)
- S A Aslam
- Eye Department, Chelsea and Westminster Hospital, London, UK.
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Alvarez MT, Figueroa MS, Teus MA. Toxic keratolysis from combined use of nonsteroid anti-inflammatory drugs and topical steroids following vitreoretinal surgery. Eur J Ophthalmol 2006; 16:582-7. [PMID: 16952098 DOI: 10.1177/112067210601600413] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To evaluate the corneal complications associated with the combined use of non-steroid anti-inflammatory drugs (NSAIDs) and topical steroids following vitreoretinal surgery. METHOD Description of corneal lesions in three patients after vitrectomy with use of topical ketorolac and prednisolone acetate. RESULTS Three eyes of three patients developed an atrophic central corneal ulcer with stromal thinning following a pars plana vitrectomy under local anesthesia. Lesions were asymptomatic and were found during a routine examination 2, 3, and 8 weeks after surgery, respectively. Surgical indications were as follows: a preretinal membrane, choroidal neovascularization, and massive uveal effusion following cataract surgery. Topical postoperative treatment was as follows: ketorolac 4 times a day, a combination of prednisolone acetate, polymyxin B, and neomycin 6 times a day, and 1% cyclopentolate 3 times a day. Suspension of ketorolac and ocular occlusion led to the resolution of corneal lesions between 2.5 and 3 months later, yielding a central superficial scarring, which showed no changes after a follow-up of 3 years. CONCLUSIONS Toxic keratolysis may appear as a secondary effect of the combined use of topical NSAIDs and steroids following vitreo retinal surgery and must be taken into account in the differential diagnosis of postoperative corneal lesions.
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Affiliation(s)
- M T Alvarez
- Departamento de Cirugia Vitreoretiniana, Vissum Madrid, Santa Hortensia 58, 28002 Madrid, Spain
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18
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Perry HD, Donnenfeld ED. An update on the use of ophthalmic ketorolac tromethamine 0.4%. Expert Opin Pharmacother 2006; 7:99-107. [PMID: 16370927 DOI: 10.1517/14656566.7.1.99] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Ketorolac tromethamine 0.4% ophthalmic solution, a recent reformulation of the original ketorolac tromethamine 0.5% solution, is indicated for the reduction of ocular pain and burning/stinging following cataract and refractive surgery. Studies have demonstrated that ketorolac tromethamine 0.4% has equivalent efficacy to ketorolac tromethamine 0.5% in reducing postsurgical inflammation and controlling pain. Several studies have demonstrated that, as well as reducing pain and ocular inflammation, ketorolac tromethamine 0.4% effectively treats cystoid macular oedema, inhibits miosis and may prevent cystoid macular oedema when used both pre- and postoperatively. Ketorolac tromethamine 0.4% is a versatile agent and is effective when used as either monotherapy or as an adjunct therapy to steroids.
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Affiliation(s)
- Henry D Perry
- Ophthalmic Consultants of Long Island, 2000 North Village Avenue, Rockville Centre, New York 11570, USA.
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19
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Williams CPR, Browning AC, Sleep TJ, Webber SK, McGill JI. A randomised, double-blind trial of topical ketorolac vs artificial tears for the treatment of episcleritis. Eye (Lond) 2005; 19:739-42. [PMID: 15359265 DOI: 10.1038/sj.eye.6701632] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To determine whether topical ketorolac (Acular) is more effective than artificial tears in treating the signs and symptoms of idiopathic episcleritis. METHODS In this prospective, randomised, double-blind study, 38 eyes of 37 patients presenting with idiopathic episcleritis were allocated to receive either topical ketorolac (0.5%) or artificial tears three times a day for 3 weeks. The severity of patients' signs (episcleral injection and the number of clock hours affected) were recorded at weekly intervals. Patients' symptoms (perceived redness and pain scores) were recorded using a daily diary. RESULTS There was no significant difference in the ophthalmic signs between the two groups at each assessment, including intensity of episcleral injection and the number of clock hours affected. No significant difference was found in the time to halve the baseline redness intensity scores (4.4 vs 6.1 days, P=0.2) or pain scores (3.6 vs 4.3 days, P=0.55). Significantly more patients on ketorolac reported stinging at the first follow-up visit (P<0.001). CONCLUSION Topical ketorolac is not significantly better than artificial tears in treating the signs or symptoms of idiopathic episcleritis.
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Affiliation(s)
- C P R Williams
- Southampton Eye Unit, Southampton General Hospital, Southampton, UK.
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20
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Linklater DR, Pemberton L, Taylor S, Zeger W. Painful Dilemmas: An Evidence-based Look at Challenging Clinical Scenarios. Emerg Med Clin North Am 2005; 23:367-92. [PMID: 15829388 DOI: 10.1016/j.emc.2004.12.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Difficult clinical decisions are a part of every emergency practitioner's life. Dealing with difficult patients and recalcitrant consultants is seldom enjoyable, but can be made more palatable through the use of some of the clinical strategies contained in this article. Knowledge of the current best evidence and a willingness to discard outdated practice ideas will help ensure that emergency practitioners continue to provide state-of-the-art medical care. Expressions of care, concern, and respect for patients' problems, and development of a therapeutic alliance with these patients will maximize patient, and ultimately physician, satisfaction.
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Affiliation(s)
- Derek R Linklater
- College of Medicine, Texas A & M University, College Station, TX 77843, USA.
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21
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Stiles J, Honda CN, Krohne SG, Kazacos EA. Effect of topical administration of 1% morphine sulfate solution on signs of pain and corneal wound healing in dogs. Am J Vet Res 2003; 64:813-8. [PMID: 12856763 DOI: 10.2460/ajvr.2003.64.813] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the effect of topical application of a 1% morphine sulfate solution (MSS) on signs of pain and wound healing in dogs with corneal ulcers and examine normal corneas immunohistochemically for the presence of mu and delta opioid receptors. ANIMALS 12 dogs. PROCEDURE A 7-mm superficial corneal ulcer was surgically created in the right eye (OD) of 10 dogs, after which gentamicin solution and 1% MSS (n = 6) or saline solution (4) was administered topically OD 3 times daily. Blepharospasm, tearing, conjunctival hyperemia, aqueous flare, esthesiometer readings, and pupil size were recorded before and 30 minutes after treatment in all dogs. Ulcer size and days to completion of healing were recorded. Corneas from 4 treated and 3 control dogs were evaluated histologically. Normal canine corneas from 2 dogs not used in the study were evaluated immunohistochemically for the presence of mu and delta opioid receptors. RESULTS Dogs treated with MSS had significantly less blepharospasm and lower esthesiometer readings than did control dogs. Duration of ulcer healing and findings of histologic evaluation of corneas did not differ between groups. Numerous delta and infrequent mu opioid receptors were identified in the corneal epithelium and anterior stroma of normal corneas. CONCLUSIONS AND CLINICAL RELEVANCE Topical use of 1% MSS in dogs with corneal ulcers provided analgesia and did not interfere with normal wound healing. Both mu and delta opioid receptors were identified in normal corneas of dogs, although the mu receptors were present only in small numbers.
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Affiliation(s)
- Jean Stiles
- Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Purdue University, West Lafayette, IN 47907, USA
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22
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Ocular Trauma. Fam Med 2003. [DOI: 10.1007/978-0-387-21744-4_70] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Weaver CS, Terrell KM. Evidence-based emergency medicine. Update: do ophthalmic nonsteroidal anti-inflammatory drugs reduce the pain associated with simple corneal abrasion without delaying healing? Ann Emerg Med 2003; 41:134-40. [PMID: 12514694 DOI: 10.1067/mem.2003.38] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Some studies have suggested that ophthalmic nonsteroidal anti-inflammatory drugs (NSAIDs) decrease the pain associated with corneal abrasions without impairing healing. This evidence-based emergency medicine (EBEM) critical appraisal reviews the literature, including additional studies appearing since the publication of an earlier EBEM review in 1999. METHODS The updated search for randomized controlled trials from 1999 to 2002 complemented the previous 1966 to 1999 search. The methodologic quality of the studies was assessed. Qualitative methods were used to summarize the study results. RESULTS The search identified 3 studies not included in the previously published review of ophthalmic NSAIDs, yielding a total of 5 blinded, randomized, placebo-controlled trials involving NSAIDs for corneal abrasions. The methodologic quality of the new studies was somewhat higher than that of the 2 original studies and was rated as "good" to "strong." The qualitative summary indicates that NSAIDs provide greater pain relief and improvement of other subjective symptoms when compared with placebo. However, whether the reduction of pain, as measured by visual analog pain scales, exceeds the minimal clinically significant difference is equivocal. The use of ophthalmic NSAIDs may decrease the need for sedating analgesics. CONCLUSION Ophthalmic NSAIDs appear to be useful for decreasing pain in patients with corneal abrasions who can afford the medication and who must return to work immediately, particularly where potential opioid-induced sedation is intolerable.
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Affiliation(s)
- Christopher S Weaver
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
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Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used agents that despite chemically heterogeneity, share similar therapeutic properties and adverse effects. Topical ophthalmic NSAIDs are limited to the relatively water soluble phenylacetic and phenylalkanoic acids as well as indole derivatives, which are more suitable for ophthalmic use. Topical ophthalmic NSAIDs are commonly used in the treatment of post-operative inflammation following cataract extraction and various surgical refractive procedures. They are also used in the prevention and treatment of cystoid macular oedema and for the treatment of allergic conjunctivitis. Absorption of topical ophthalmic NSAIDs through the nasal mucosa results in systemic exposure and the occurrence of adverse systemic events, including exacerbation of bronchial asthma. Local irritant effects of topical ophthalmic NSAIDs include conjunctival hyperaemia, burning, stinging and corneal anaesthesia. A more serious complication involves the association of topical ophthalmic NSAIDs with indolent corneal ulceration and full-thickness corneal melts. Analysis of NSAID-associated corneal events implicates the now defunct generic dicolfenac product, diclofenac sodium ophthalmic solution as the agent primarily responsible. However, these events generated a renewed interest in the safety of ophthalmic NSAIDs and a scrutiny of the pharmacology regarding NSAID action in the eye. An elucidation of possible pharmacodynamic explanations of NSAID-induced corneal injury includes the role of epithelial hypoxia, which not only appears to aid in determining the metabolic destination of arachidonate, it may play a key role in orchestrating a novel inflammatory response unrelated to prostanoid formation. The use of NSAIDs under conditions of corneal hypoxia may therefore not only result in a disappointing therapeutic response, it may result in a paradoxical inflammatory exacerbation. Other potential mechanisms include the relationship between NSAIDs and corneal matrix metalloproteinase and direct toxicity due to cytotoxic excipients such as surfactants, solubilisers and preservatives found in topical NSAID ophthalmic preparations. In general, ophthalmic NSAIDs may be used safely with other ophthalmic pharmaceuticals; however, concurrent use of agents known to adversely effect the corneal epithelium, such as gentamicin, may lead to increased corneal penetration of the NSAID. The concurrent use of NSAIDs with topical corticosteorids in the face of significant pre-existing corneal inflammation has been identified as a risk factor in precipitating corneal erosions and melts and should be undertaken with caution. Until clinical evidence dictates otherwise, data supporting theories of potential pharmacodynamic mechanisms of NSAID injury do not alter the favorable benefit-risk ratio of ophthalmic NSAID use when employed in an appropriate and judicious manner.
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Affiliation(s)
- Bruce I Gaynes
- Department of Ophthalmology, Rush University College of Medicine, Chicago, IL 60612, USA.
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25
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Affiliation(s)
- Allan Joseph Flach
- Department of Ophthalmology, University of California, San Francisco, San Francisco, CA 94143, USA
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Solomon KD, Vroman DT, Barker D, Gehlken J. Comparison of ketorolac tromethamine 0.5% and rimexolone 1% to control inflammation after cataract extraction. Prospective randomized double-masked study. J Cataract Refract Surg 2001; 27:1232-7. [PMID: 11524195 DOI: 10.1016/s0886-3350(00)00832-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To compare the efficacy of a topical nonsteroidal anti-inflammatory agent (ketorolac tromethamine 0.5%) with that of a topical steroid (rimexolone 1%) to control inflammation after cataract surgery. SETTING Storm Eye Institute, Department of Ophthalmology, Medical University of South Carolina, Charleston, South Carolina, USA. METHODS Thirty-six patients were prospectively and randomly assigned to receive topical treatment with either ketorolac tromethamine 0.5% or rimexolone 1% starting the day after routine cataract extraction. Treatment was masked to both patient and investigator. Each patient had uneventful small incision phacoemulsification with placement of a foldable posterior chamber intraocular lens. Patients used 1 of the 2 antiinflammatory agents 4 times each day starting 24 hours after surgery. No antiinflammatory medications were used preoperatively, intraoperatively, or for 24 hours postoperatively. Signs and symptoms of inflammation, intraocular pressure (IOP), and Kowa cell and flare measurements were evaluated 1, 4, 7, and 30 days postoperatively. RESULTS There was no statistically significant difference in any measurement of postoperative inflammation between the 2 groups. There was no difference in objective or subjective cell and flare measurements. In addition, there was no difference in IOP measurements between groups. CONCLUSIONS Ketorolac tromethamine 0.5% was as effective as rimexolone 1% in reducing inflammation after cataract surgery. These results suggest that ketorolac tromethamine 0.5% is a safe and effective antiinflammatory alternative to steroids after cataract extraction.
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Affiliation(s)
- K D Solomon
- Storm Eye Institute, Department of Ophthalmology, Medical University of South Carolina, Charleston, 29425, USA
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27
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Le Sage N, Verreault R, Rochette L. Efficacy of eye patching for traumatic corneal abrasions: a controlled clinical trial. Ann Emerg Med 2001; 38:129-34. [PMID: 11468606 DOI: 10.1067/mem.2001.115443] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE We sought to evaluate the efficacy of eye patching in the treatment of traumatic corneal abrasions in terms of time to healing and reduction in pain and discomfort. METHODS One hundred sixty-three patients presenting at the emergency department of a large university-affiliated hospital with traumatic corneal abrasions were included in this single-blind prospective controlled trial. Eligible patients were assigned to 1 of 2 treatment regimens: topical antibiotic ointment and occlusive patch over the affected eye (n=82) or topical antibiotic ointment 4 times a day without an occlusive patch (n=81). Patients were reexamined every 24 hours until corneal healing occurred. Healing evaluation was performed by the emergency physician, using a slit lamp with fluorescein staining, without knowledge of the patient's assignment to a treatment group. The degree of discomfort was assessed at each visit by using a visual analog scale. RESULTS Both treatment groups were similar regarding size of the corneal lesions, delay from trauma to first ED visit, presence of foreign body or siderosis, initial degree of discomfort, and presence of specific symptoms (irritation, foreign body sensation, photophobia, redness, and pain). In the patched group, cumulative incidences of healing were 51%, 78%, and 92% after 1, 2, and 3 days, respectively, compared with 60%, 83%, and 88% in the nonpatched group. In the patched group, symptoms of initial discomfort decreased by 4.8, 4.1, and 5.5 cm after 1, 2, and 3 days, respectively, compared with 3.3, 5.1, and 6.5 cm in the nonpatched group. CONCLUSION Eye patching does not appear to be beneficial in the treatment of traumatic corneal abrasions compared with topical antibiotic ointment.
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Affiliation(s)
- N Le Sage
- Research Center, Centre Hospitalier Affilié de l'Université Laval (CHA), Quebec City, Quebec, Canada.
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Goyal R, Shankar J, Fone DL, Hughes DS. Randomised controlled trial of ketorolac in the management of corneal abrasions. ACTA OPHTHALMOLOGICA SCANDINAVICA 2001; 79:177-9. [PMID: 11284758 DOI: 10.1034/j.1600-0420.2001.079002177.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
PURPOSE To evaluate the role of topical non-steroidal anti-inflammatory agents (NSAIDs) in the management of corneal abrasions with respect to symptoms and healing. METHODS The study was designed as a prospective, single center, randomised, placebo controlled, double-blinded trial. Eighty-eight consecutive patients with non-infective, non-contact lens related traumatic or foreign body removal related corneal abrasions were recruited to this study. They were randomised into two groups. Both groups were given a single instillation of Gutt. cyclopentolate 0.5% followed by chloramphenicol eye ointment four times a day until the following day. In addition, the treatment group received topical Ketorolac trometamol 0.5% ophthalmic solution while the control group received placebo Liquifilm tears. Patients were assessed at presentation and about twenty-four hours later for subjective symptoms, abrasion size and any associated complications. RESULTS There was no statistical difference in the two groups at base line and twenty-four hour follow-up when assessed for five subjective symptoms of pain, photophobia, grittiness, watering and blurring of vision. However, those receiving topical ketorolac required significantly less additional oral analgesics (p=0.001). There was no difference in the rate of healing. CONCLUSION Use of topical ketorolac may be a useful adjunct in the management of corneal abrasions.
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Affiliation(s)
- R Goyal
- Department of Ophthalmology, St. Woolos Hospital, Newport, Wales
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Congdon NG, Schein OD, von Kulajta P, Lubomski LH, Gilbert D, Katz J. Corneal complications associated with topical ophthalmic use of nonsteroidal antiinflammatory drugs. J Cataract Refract Surg 2001; 27:622-31. [PMID: 11311634 DOI: 10.1016/s0886-3350(01)00801-x] [Citation(s) in RCA: 97] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE To explore the potential association between adverse corneal events and the use of topical nonsteroidal antiinflammatory drugs (NSAIDs). SETTING Practice-based reports. METHODS A detailed case-reporting form and request for medical records were sent to all practices reporting cases of corneal or conjunctival pathology in association with the use of topical NSAIDs to the American Society of Cataract and Refractive Surgery. Cases were classified as "mild," "moderate," or "severe" according to predetermined clinical criteria. RESULTS Records of 140 eyes (129 patients) were reviewed; 51 cases (36.4%) were mild, 55 (39.3%) moderate, and 34 (24.3%) severe. An association with a specific topical NSAID was confirmed in 117 cases (81.8%). Most confirmed cases (53.8%) involved generic diclofenac (Falcon). Cases associated with brand diclofenac (Voltaren, CIBA Vision) and ketorolac (Acular, Allergan) were more likely to have ocular comorbidity and to have received significantly higher total doses of NSAIDs. Neither "off-label" use nor use of any specific agent was associated with severe compared to mild or moderate disease. However, patients with more severe adverse events were more likely to have a history of diabetes, previous surgery in the affected eye, and surgery other than cataract. Cases not occurring in the perioperative period had significantly worse outcomes, had significantly more ocular comorbidities, and received nearly 3 times the dose of NSAIDs. CONCLUSIONS While topical NSAIDs as a class may be associated with severe adverse events, such events appeared to require potentiation in the form of high total doses, ocular comorbidities, or both with Acular and Voltaren. Severe adverse events might have been more likely to occur at lower doses and in routine postoperative settings with generic diclofenac.
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Affiliation(s)
- N G Congdon
- The Wilmer Eye Institute, Dana Center for Preventive Ophthalmology, Baltimore, MD, USA
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Bridge HS, Montgomery CJ, Kennedy RA, Merrick PM. Analgesic efficacy of ketorolac 0.5% ophthalmic solution (Accular) in paediatric strabismus surgery. Paediatr Anaesth 2000; 10:521-6. [PMID: 11012956 DOI: 10.1046/j.1460-9592.2000.00534.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This prospective double-blind study was designed to assess the analgesic efficacy of ketorolac 0.5% ophthalmic solution compared with placebo in 30 healthy children undergoing extraocular muscle recession for correction of strabismus. After paracetamol 20 mg.kg-1 preoperatively, a standard anaesthetic was given. There were no significant differences in Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and faces pain scale (FPS) scores, requirement for supplementary analgesia or in postoperative vomiting between the two groups over the following 24 h. This study did not demonstrate improved postoperative analgesia when topical ketorolac eye drops were given in addition to paracetamol. This observed lack of efficacy may reflect difficulties in the use of CHEOPS and FPS in this age group with this pain model.
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Affiliation(s)
- H S Bridge
- Department of Anaesthesia and Ophthamology, British Columbia's Children's Hospital and University of British Columbia, Vancouver, Canada
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Shields SR. Managing eye disease in primary care. Part 2. How to recognize and treat common eye problems. Postgrad Med 2000; 108:83-6, 91-6. [PMID: 11043082 DOI: 10.3810/pgm.2000.10.1780] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Many patients with symptomatic eye conditions present initially to their primary care physician. Comprehensive treatment of such conditions as dry eye syndrome, blepharitis, styes, chalazia, conjunctivitis, congenital nasolacrimal duct obstruction, superficial foreign bodies, corneal abrasion, and subconjunctival hemorrhage can often be provided in the primary care setting. Patients with persistent or severe conditions, particularly those involving foreign bodies and corneal abrasions due to high-velocity injuries, should be referred for immediate care by an ophthalmologist.
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Abstract
Over the past quarter century, advances in our understanding of corneal anatomy, physiology, and wound healing have all played an integral role in the management of corneal trauma. As the etiologies of corneal trauma have changed, so has our understanding of the impact of injury on corneal function as it relates to visual rehabilitation. Numerous new classes of antibiotics, antiinflammatory agents, and tissue adhesives have emerged. Occlusive therapy has advanced from simple pressure patching bandage soft contact lenses and collagen shields. Surgical instrumentation, operating microscopes, viscoelastic substances, and suture materials have all improved the outcomes of corneal trauma repair. Improved understanding of the refractive properties of the cornea through topography and alternative suture techniques has helped us restore the natural corneal curvature and visual outcomes. Consequently, in the last quarter of this century our therapeutic approaches to cornea trauma, both medical and surgical, have improved.
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Affiliation(s)
- M S Macsai
- Division of Ophthalmology, Evanston Northwestern Healthcare, Northwestern University Medical School, Illinois, USA
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Abstract
PURPOSE The history of contact lenses has occurred in the latter half of the 20th century. In particular, events in the 1970s through the 1980s related to the invention of soft, hydrogel contact lenses have revolutionized the contact lens industry and the eye care attached to it. This article recounts that history from the perspective of market forces, inventions, and discoveries about the physiologic functioning of the cornea. METHODS The relevant literature is critically reviewed. RESULTS Discoveries about the oxygen needs of the cornea and consumer pressure for clear, comfortable, around-the-clock vision have resulted in a history of rigid gas permeable and soft lenses that leads to today's contact lens picture. The short-term and long-term effects of chronic hypoxia and the levels of lens oxygen transmissibility necessary to avoid them have been well-described. The advent of the soft lens, followed by the "human experiment" with initial extended-wear modalities, led to the advent of the disposable soft contact lens. CONCLUSIONS In the past 25 years, the development and wide acceptance of soft contact lenses have revolutionized the management of refractive error and corneal diseases.
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Affiliation(s)
- T T McMahon
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, 60612, USA
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Vetrugno M, Maineo A, Quaranta GM, Cardia L. A randomized, double-masked, clinical study of the efficacy of four nonsteroidal anti-inflammatory drugs in pain control after excimer laser photorefractive keratectomy. Clin Ther 2000; 22:719-31. [PMID: 10929919 DOI: 10.1016/s0149-2918(00)90006-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE This study assessed the efficacy of 4 nonsteroidal anti-inflammatory drugs (NSAIDs) after excimer laser photorefractive keratectomy (PRK). BACKGROUND Inadequate control of pain after PRK surgery can be a severe source of distress to patients and can interfere with their willingness to undergo a second PRK procedure. METHODS This randomized, double-masked, placebo-controlled clinical study was conducted in 125 patients. Four NSAIDs (diclofenac, flurbiprofen, ketorolac, and indomethacin) were tested against a placebo group (artificial tears). Pain levels after PRK were quantified using Present Pain Intensity (PPI) and Pain Rating Indices based on rank values (PRI[R]) scores, both of which were calculated using patient responses to a modified McGill Pain Questionnaire. The PRI(R) consisted of 4 subscales-sensory (S), affective (A), evaluative (E), and miscellaneous (M)-as well as a total score (T). RESULTS Three hours after PRK, no differences in PPI scores were found between the ketorolac, diclofenac, and indomethacin groups, whereas placebo was significantly less effective than the NSAIDs. Patients who received flurbiprofen reported PPI scores that were significantly lower (P < 0.001) than those of patients who received diclofenac and indomethacin, but PPI scores in the flurbiprofen and the ketorolac groups did not differ significantly. Twenty-four hours after surgery, patients treated with flurbiprofen, ketorolac, and diclofenac reported the lowest PPI scores compared with those treated with indomethacin and placebo (P < 0.001). Moreover, flurbiprofen-treated patients also had the lowest PRI(R)T scores (P < 0.001). When the pain rating index was examined by subclass, a significantly lower PRI(R)S score was detected in the flurbiprofen group at 24 hours (P < 0.001). The PRI(R)A score was significantly higher in the placebo and indomethacin groups compared with the other groups (P < 0.001). At the 48- and 72-hour time points, flurbiprofen-treated patients again reported significantly lower PPI and PRI(R)T scores (P < 0.001 for both) in pair-wise comparisons with the other treatment groups. The number of patients who self-administered additional oral analgesics did not differ significantly between the groups. However, the mean number of analgesic tablets used was significantly higher in the placebo group than in any NSAID group (P < 0.001). The ketorolac group had the largest number of patients complaining of itching (P < 0.043). No other subjective symptoms were significantly different across groups. Finally, all NSAIDs, except flurbiprofen, prolonged the mean reepithelialization period slightly (P < 0.001). CONCLUSIONS Flurbiprofen appeared to be the most effective NSAID for the treatment of pain, even at 24 hours after surgery when pain was at a maximum.
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Affiliation(s)
- M Vetrugno
- Department of Ophthalmology-Otorhinolaryngology, University of Bari, Italy.
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Szucs PA, Nashed AH, Allegra JR, Eskin B. Safety and efficacy of diclofenac ophthalmic solution in the treatment of corneal abrasions. Ann Emerg Med 2000; 35:131-7. [PMID: 10650230 DOI: 10.1016/s0196-0644(00)70132-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
STUDY OBJECTIVE To determine whether the use of diclofenac ophthalmic solution is a safe and effective analgesic in the treatment of traumatic corneal abrasions in the emergency department. METHODS We conducted a prospective, randomized, double-blinded, placebo-controlled clinical trial. Consenting consecutive patients with corneal abrasions who presented to a community-based ED from August through February 1998 were randomly assigned to receive either diclofenac or control vehicle drops. Pain relief was measured using a visual Numeric Pain Intensity Scale (NPIS) before and after treatment. Exclusion criteria were as follows: age younger than 18 years, pregnancy, history of glaucoma, ocular infection, recent eye surgery, other signs of ocular trauma, narcotics within 6 hours, minimal pain (NPIS score <3), and any allergy to diclofenac or nonsteroidal anti-inflammatory drugs. Patients were discharged with study drug or control vehicle solution, a topical antibiotic, oxycodone-acetaminophen as a rescue analgesic, and a pain diary. The outcome measurements were improvement in NPIS score 2 hours after treatment, use of oxycodone-acetaminophen, and occurrence of any adverse effects. RESULTS Forty-nine patients were enrolled in the study; 25 received diclofenac and 24 received control vehicle drops. Both groups were similar in gender, age, pretreatment pain duration, NPIS score, and analgesic use. There was significantly greater improvement in the 2-hour NPIS score in the diclofenac group (3.1; 95% confidence interval [CI] 2.3 to 4) compared with the control group (1.0; 95% CI 0.1 to 2.0). The difference between the 2 groups was 2.1+/-1.3 (95% CI 0.8 to 3.4). There was a trend toward fewer patients taking rescue oxycodone-acetaminophen in the diclofenac group (20%; 95% CI 4% to 36%) versus the control group (42%; 95% CI 22% to 62%). Other than transient mild stinging, there were no complications associated with diclofenac use. CONCLUSION Diclofenac ophthalmic solution appears to be a safe and effective analgesic in the treatment of traumatic corneal abrasions in the ED.
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Affiliation(s)
- P A Szucs
- Department of Emergency Medicine, Morristown Memorial Hospital, Morristown, NJ 07962, USA.
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Cwiertnia B, Hladon T, Stobiecki M. Stability of diclofenac sodium in the inclusion complex with beta-cyclodextrin in the solid state. J Pharm Pharmacol 1999; 51:1213-8. [PMID: 10632077 DOI: 10.1211/0022357991776930] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
The aim of this study was to characterize the thermal stability of diclofenac sodium both alone and in the inclusion complex with beta-cyclodextrin in the solid state, by determination of the number of the products of its decomposition, which were identified by GC-MS. The molar ratio of diclofenac sodium in the inclusion complex with beta-cyclodextrin was 1:1. The decomposition of diclofenac sodium both alone and in inclusion complex with beta-cyclodextrin occurred according to the first-order reaction. The HPLC of the samples thermostated at 80 degrees C gave five products of decomposition, which were identified by GC-MS. Diclofenac sodium in the inclusion complex with beta-cyclodextrin was more thermally stable. Thermal decomposition of diclofenac sodium leads to formation of five products, of which 4-chloro-10H-9-acridinone had not been reported previously in the literature.
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Affiliation(s)
- B Cwiertnia
- Department of Inorganic and Analytical Chemistry, Karol Marcinkowski University of Medical Sciences, Poznan, Poland
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Brown MD, Cordell WH, Gee AS. Do ophthalmic nonsteroidal anti-inflammatory drugs reduce the pain associated with simple corneal abrasion without delaying healing? Ann Emerg Med 1999; 34:526-34. [PMID: 10499953 DOI: 10.1016/s0196-0644(99)80055-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- M D Brown
- Department of Emergency Medicine, Spectrum Health, Michigan State University Program in Emergency Medicine, Grand Rapids, MI, USA.
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McDonald MB, Wyse TB, Borodkin MJ, Ocmand A, Shoelson B, Thompson H. Comparison of the effectiveness of 4 anti-inflammatory drops in relieving photophobia after pupil dilation. J Cataract Refract Surg 1999; 25:405-10. [PMID: 10079447 DOI: 10.1016/s0886-3350(99)80090-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To compare the relative effectiveness of diclofenac, flurbiprofen, ketorolac, and prednisolone acetate in relieving photophobia after pupil dilation for fundus examination. SETTING Eye, Ear, Nose, and Throat Hospital, New Orleans, Louisiana, USA. METHODS This prospective, blind, placebo-controlled study comprised 105 patients randomly assigned to 1 of 10 treatment groups. Five minutes after instillation of dilating drops, each patient received drops of different test medications in the right and left eyes. Light sensitivity and pupil measurement tests were performed over 2 hours after the pharmacological mydriasis. After photostimulation, patients were asked to rate their photosensitivity on numerical and analog scales and to indicate a filter value required to alleviate right-induced discomfort. Test results were analyzed to detect differences among the pain levels associated with each treatment. RESULTS There were no significant differences between the placebo and any active treatment drug at any time during the study. CONCLUSION These findings suggest that mediators other than prostaglandins may have a role in photosensitivity or that increased postmydriatic photosensitivity is a result of higher light levels entering the eye through the dilated pupil.
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Affiliation(s)
- M B McDonald
- Refractive Surgery Center of the South, Eye, Ear, Nose, and Throat Hospital, New Orleans, Louisiana 70115, USA
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Carley S. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Topical analgesia in corneal abrasions. J Accid Emerg Med 1999; 16:62-3. [PMID: 10454820 PMCID: PMC1343260 DOI: 10.1136/emj.16.1.62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Thompson S. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Wound cleaning methods. J Accid Emerg Med 1999; 16:63-4. [PMID: 10454821 PMCID: PMC1343261 DOI: 10.1136/emj.16.1.63] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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