Comparison of the Tolerability of Diclofenac and Nepafenac

Pain control and subconjunctival haemorrhage after intravitreal injection using cooled anaesthetic eyedrops and antiseptics: A prospective, double-blind, randomized controlled trial

PURPOSE

To evaluate whether cooled anaesthetic eyedrops and antiseptics alleviate pain and minimise subconjunctival haemorrhage following intravitreal injection.

METHODS

A prospective, double-masked, randomised controlled trial of 100 participants receiving either cooled (n = 50) or room temperature (n = 50) topical anaesthetic eyedrops and antiseptics before receiving an injection of bevacizumab. Baseline tolerability was estimated using a self-reported pain sensitivity questionnaire.

RESULTS

Overall tolerability was comparable between the study group and the control group (0.75 ± 0.13 vs. 0.74 ± 0.14, respectively, p = 0.99). Subconjunctival haemorrhage incidence was similar in both groups (80% vs. 86%, respectively, p = 0.113), as was subconjunctival haemorrhage size (2.75 ± 5.51 mm2 vs. 5.53 ± 10.72 mm2 , respectively, p = 0.11). Sub-group analysis demonstrated that the participants taking daily ocular eyedrops who received cooled anaesthetic eyedrops and antiseptics reported less pain at 10 min and less burning sensation at 24 h compared with matched controls (0.67 ± 1.50 vs. 2.50 ± 3.03, respectively, p = 0.040 and 0.00 ± 0.00 vs. 1.44 ± 2.96, respectively, p = 0.045). Participants who received cooled eyedrops and did not use antithrombotic therapy had smaller-sized subconjunctival haemorrhages compared with matched controls (1.55 ± 1.87 mm2 vs. 8.29 ± 14.61 mm2 , respectively, p = 0.038). Participants with hypertension who received cooled eyedrops had smaller-sized subconjunctival haemorrhage compared with matched controls (2.33 ± 4.99 mm2 vs. 6.89 ± 12.41 mm2 , respectively, p = 0.045).

CONCLUSION

The benefit of using cooled anaesthetic eyedrops and antiseptics to alleviate pain and minimise subconjunctival haemorrhage following intravitreal injection was not proven in the general population. It may be beneficial in part for some patients, such as those who regularly use eyedrops, patients with hypertension or those not on antithrombotic therapy.

Efficacy of Pretreatment with Preservative-Free Topical Bromfenac in Improving Post-Intravitreal-Injection Pain: A Prospective Pilot Study

(1) Background: To determine the analgesic effect of pretreatment topical bromfenac instillation in patients undergoing intravitreal anti-VEGF treatment. (2) Methods: A prospective, non-randomized pilot study was conducted in patients scheduled to receive repeated intravitreal anti-VEGF injections at a single tertiary hospital. Before the planned second injection, the patients received topical bromfenac eye drops twice a day for 3 days. At 1, 6, and 24 h after the first and second injections, the post-injection pain scores were determined using the numerical rating scale (NRS) telephonically. (3) Results: A total of 28 patients were enrolled in this study. After the first intravitreal injection, the NRS pain scores were 4.04 ± 1.90 at 1 h, 1.57 ± 1.75 at 6 h, and 0.93 ± 1.27 at 24 h. The pain scores after the second intravitreal injection significantly decreased at each measurement time point (p = 0.002, 0.055, and 0.004, respectively) compared to the first injection. (4) Conclusions: The use of topical bromfenac eye drops before intravitreal injection can lead to a significant improvement in injection-related pain scores, which is the basis for a future large-scale randomized comparative study.

Nonopioid Analgesics for the Perioperative Geriatric Patient: A Narrative Review

Management of acute perioperative pain in the geriatric patient can be challenging as the physiologic and pharmacokinetic changes associated with aging may predispose older patients to opioid-related side effects. Furthermore, elderly adults are more susceptible to postoperative delirium and postoperative cognitive dysfunction, which may be exacerbated by both poorly controlled postoperative pain and commonly used pain medications. This narrative review summarizes the literature published in the past 10 years for several nonopioid analgesics commonly prescribed to the geriatric patient in the perioperative period. Nonopioid analgesics are broken down as follows: medications prescribed throughout the perioperative period (acetaminophen and nonsteroidal anti-inflammatory drugs), medications limited to the acute perioperative setting (N-methyl-D-aspartate receptor antagonists, dexmedetomidine, dexamethasone, and local anesthetics), and medications to be used with caution in the geriatric patient population (gabapentinoids and muscle relaxants). Our search identified 1757 citations, but only 33 specifically focused on geriatric analgesia. Of these, only 21 were randomized clinical trials' and 1 was a systematic review. While guidance in tailoring pain regimens that focus on the use of nonopioid medications in the geriatric patient is lacking, we summarize the current literature and highlight that some nonopioid medications may extend benefits to the geriatric patient beyond analgesia.

Nonsteroidal anti-inflammatory drugs for retinal neurodegenerative diseases

Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most common prescription drugs for inflammation, and topical NSAIDs are often used in ophthalmology to reduce pain, photophobia, inflammation, and edema. In recent years, many published reports have found that NSAIDs play an important role in the treatment of retinal neurodegenerative diseases, such as age-related macular degeneration (AMD), diabetic retinopathy (DR), glaucoma, pathological myopia, and retinitis pigmentosa (RP). The aim of the current review is to provide an overview of the role of various NSAIDs in the treatment of retinal neurodegenerative diseases and the corresponding mechanisms of action. This review highlighted that the topical application of NSAIDs for the treatment of retinal degenerative diseases has been studied to a remarkable extent and that its beneficial effects in many diseases have been proven. In the future, prospective studies with large study populations are required to extend these effects to clinical settings.

REDUCTION OF POSTINTRAVITREAL INJECTION PAIN USING ICE: An Open-Label Interventional Randomized Controlled Trial

PURPOSE

Intravitreal injections of intraocular therapeutic agents are a common and effective treatment for various retinal pathologies. Patient discomfort related to injection is a potential barrier to treatment. Our aim in this study was to evaluate whether cooling the eye using topical ice compresses before intravitreal injection will reduce pain or bleeding.

METHODS

This randomized controlled open-label study included 42 patients. All patients received a standard topical anesthesia protocol and then were randomly assigned to either receive a placement of ice packs (intervention group) or a room-temperature pack (control group) on the eyelid, 2 minutes before the intravitreal injection. Patients' discomfort, itching, burning and pain (using visual analog scale), and bleeding size (using photographs) were measured 1 and 10 minutes after the injection. Tolerability was calculated by averaging patients' discomfort, itching, burning, and pain scores.

RESULTS

At 1 minute, pain (1.95 vs. 4.27, P = 0.01) and overall tolerability (1.66 vs. 2.98, P = 0.03) were significantly lower in patients receiving ice packs. At 10 minutes, pain (1.6 vs. 3.73, P = 0.02), burning (0.9 vs. 3.09, P = 0.007), discomfort (2.1 vs. 4.27, P = 0.008), and overall tolerability (1.23 vs. 2.87, P = 0.004) were all significantly lower in the ice group compared with the controls. Bleeding size (area or circumference) was not statistical different between groups.

CONCLUSION

Topical ice patch administered before intravitreal injection significantly decreased pain and overall tolerability. This simple and inexpensive method may be used to ameliorated pain and improve tolerability.

Nepafenac-Loaded Cyclodextrin/Polymer Nanoaggregates: A New Approach to Eye Drop Formulation

The topical administration route is commonly used for targeting therapeutics to the eye; however, improving the bioavailability of drugs applied directly to the eye remains a challenge. Different strategies have been studied to address this challenge. One of them is the use of aggregates that are formed easily by self-assembly of cyclodextrin (CD)/drug complexes in aqueous solution. The aim of this study was to design a new eye drop formulation based on aggregates formed between CD/drug complexes. For this purpose, the physicochemical properties of the aggregates associated with six CDs and selected water-soluble polymers were analysed. Complex formation was studied using differential scanning calorimetry (DSC), Fourier-transform infrared spectroscopy (FT-IR) and ¹H nuclear magnetic resonance spectroscopy (¹H-NMR). Results showed that HPβCD performed best in terms of solubilization, while γCD performed best in terms of enhancing nanoaggregate formation. Formation of inclusion complexes was confirmed by DSC, FT-IR and ¹H-NMR studies. A mixture of 15% (w/v) γCD and 8% (w/v) HPβCD was selected for formulation studies. It was concluded that formulations with aggregate sizes less than 1 µm and viscosity around 10–19 centipoises can be easily prepared using a mixture of CDs. Formulations containing polymeric drug/CD nanoaggregates represent an interesting strategy for enhanced topical delivery of nepafenac.

Postoperative management in cataract surgery: nepafenac and preservative-free diclofenac compared

PURPOSE

Current cataract surgery guidelines recommend routine use of topical nonsteroidal anti-inflammatory drugs (NSAIDs) in preventing pseudophakic cystoid macular oedema (PCME). Here, we compare the clinical efficacy and tolerability of two potent NSAIDs, nepafenac and preservative-free diclofenac following cataract surgery.

METHODS

Randomized, double-blind, prospective single-centre study. Ninety-six eyes of 95 patients undergoing routine cataract surgery were randomized 1:1 either to nepafenac (Nevanac, 1 mg/ml) or diclofenac (Dicloabak, 1 mg/ml) for 3 weeks. Seventy-three patients accounting for 73 eyes completed the entire follow-up. Aqueous flare and central retinal thickness (CRT) analysis were conducted preoperatively and at control visits 28 days and 3 months after surgery. A structured home questionnaire and interview were used to record any adverse effects of the topical medications, subjective visual recovery and the dispenser's ease of use.

RESULTS

No differences were observed between the groups for aqueous flare, CRT, speed of recovery or visual acuity gain. Seven patients (16%) on nepafenac and 20 patients (48%) on preservative-free diclofenac reported symptoms related to topical use of NSAID medications (p = 0.001).

CONCLUSION

No differences in clinical efficacy were found between potent NSAIDs, while tolerability might be an issue.