Intraoperative ketorolac and eye pain after viteoretinal surgery: a prospective, randomized, placebo-controlled study

Efficacy of Perioperative Intravenous Dexamethasone on Postoperative Analgesia in Scleral Buckle Surgery: A Randomized Clinical Trial

BACKGROUND AND OBJECTIVE

Postoperative pain is frequently reported following scleral buckle (SB) surgery. This study assessed the efficacy of perioperative dexamethasone on postoperative pain and opioid use following SB.

MATERIALS AND METHODS

Forty-five patients with rhegmatogenous retinal detachments undergoing SB or SB and pars plana vitrectomy were randomly assigned to either standard care of postoperative oral acetaminophen and oxycodone/acetaminophen as needed or standard care plus 8 mg single-dose peri-operative intravenous dexamethasone. A questionnaire was administered on postoperative days 0, 1, and 7 to determine visual analog scale 0 to 10 pain score and number of opioid tablets consumed.

RESULTS

Mean visual analog scale score and opioid use were significantly lower in the dexamethasone group on postoperative day 0 compared with control (2.76 ± 1.96 vs 5.64 ± 3.40, P = .002; 0.41 ± 0.92 vs 1.34 ± 1.43, P = .016). The dexamethasone group also demonstrated significantly lower total opioid use (0.97 ± 1.88 vs 3.69 ± 5.32, P = .047). No significant differences in pain score or opioid use were observed on days 1 or 7 (P = .078; P = .311; P = .326; P = .334).

CONCLUSION

Single-dose intravenous dexamethasone following SB can significantly reduce postoperative pain and opioid use. [Ophthalmic Surg Lasers Imaging Retina 2023;54(x):X-X.].

Risk factors for postoperative eye pain in patients with non-painful eye disease undergoing pars plana vitrectomy: the VItrectomy Pain (VIP) study

BACKGROUND

Pars plana vitrectomy (PPV), a surgical procedure used to treat different ophthalmic pathologies, could be associated with moderate to severe eye pain. The aim of the present study was to evaluate the incidence of postoperative eye pain and its risk factors following PPV in a selected population of patients with non-painful eye disease, receiving regional anesthesia and moderate sedation with benzodiazepines, without use of narcotics.

METHODS

Single-center, prospective observational cohort study. We recorded the presence of pain at operating room discharge, at 6 and 24 hours, using the numeric rating scale (NRS). We recorded also age, sex, ethnic origin, American Society of Anaesthesia physical status (ASA PS) classification, Charlson Comorbidity Index, the etiology of the vitreoretinal pathology, length of surgery, and type of surgical procedure performed.

RESULTS

Eye pain (NRS>3) was present in three patients (0.7%) at operating room discharge, 59 (13.2%) at six and 65 (14.6%) at 24 hours after surgery. LASSO logistic regression analysis identified age, ASA PS, race, along with tamponade as independent risk factors for eye pain at six hours. Scleral buckling was selected for eye pain at 24 hrs.

CONCLUSIONS

A protocol for pain control after PPV should be considered, especially in younger, non-Caucasian people, and patients with high ASA PS grade. Moreover, attention must be paid when additional surgical procedures are requested, restricting them to selected patients, and using the appropriate agent for intraocular tamponade.

Effect of Intravenous Acetaminophen on Postoperative Pain in Vitrectomy: A Randomized, Double-Blind, Clinical Trial

Background

Nowadays, pain, nausea, and vomiting are regarded as important complications of anesthesia and surgery. The current study aimed at assessing the effect of preemptive intravenous acetaminophen on control of pain, nausea, vomiting, shivering, and drowsiness following the general anesthesia for retina and/or vitrectomy surgeries.

Methods

In a randomized, double-blind, clinical trial, 83 candidates for retina or vitrectomy eye surgery under general anesthesia were distributed into 3 groups: A) 41 patients in the control group who received 100 mL of normal saline just before the surgery and 100 mL of normal saline 20 minutes before the end of surgery; B) 21 patients in the preemptive group who received acetaminophen 15 mg/kg in 100 mL normal saline just before the surgery and 100 mL normal saline 20 minutes before the end of surgery; C) 21 patients in the preventive group who received 100 mL normal saline just before the surgery and acetaminophen 15 mg/kg in 100 mL normal saline 20 minutes before the end of surgery. Pain, nausea, vomiting, and shivering were assessed at the recovery and 2, 4, and 24 hours after the operation. Anesthesia emergence situation was assessed after arrival in the recovery room by the Richmond agitation-sedation scale (RASS) questionnaire. Blood pressure and heart rate were recorded before anesthesia induction, just after intubation, before extubation, and on discharge from the recovery room.

Results

Total intraoperative fentanyl, duration of operation, and duration of anesthesia were not different among the studied groups. Vital signs were not statistically different among the groups at before anesthesia induction, just after intubation, before extubation, and on discharge from the recovery room. Thirty-three patients in the control group (87.8%), 11 in preemptive (52.4%), and 14 in preventive groups (66.7%) needed acetaminophen in the first 24 hours after the surgery (P value = 0.008). Pain scores measured by visual rating scale (VRS) was lower in the preemptive and preventive groups, compared with those of the control group, in the recovery (P value = 0.006), 2 hours after the surgery (P value = 0.008), and 4 hours after the surgery (P value = 0.012), but not in 24 hours after the operation (P value = 0.1).

Conclusions

Intravenous acetaminophen administered as preemptive or preventive medication was effective and safe to control acute postoperative pain and analgesic request after the vitrectomy eye surgery.

Topical nepafenac 0.1% alone versus prednisolone acetate 1% as postoperative anti-inflammatory agents in small gauge vitrectomy

AIM

To compare the efficacy of postoperative topical nepafenac (0.1%) with prednisolone acetate (1%) as anti-inflammatory agents in eyes undergoing Transscleral Sutureless Vitrectomy (TSV).

SETTINGS AND DESIGN

Prospective, double-blind, randomized, single center clinical study.

MATERIALS AND METHODS

Eighty eyes of 76 subjects, who underwent small gauge vitrectomy, were included in the study. The subjects who fulfilled the inclusion criteria were randomized to either topical nepafenac only (Group 1) or prednisolone acetate only (Group 2), to be used as postoperative anti-inflammatory agents. The subjects were reviewed on days 1, 30, and 90. Ocular and adnexal inflammation was appropriately graded using the standardized classification. Grading of ocular pain was done on the Visual Analog Scale (VAS).

STATISTICAL ANALYSIS

The Wilcoxon rank-sum test, using two-sided analysis, was used.

RESULTS

During the follow-up, both Group 1 and Group 2 did not have a significant difference related to the grade of the anterior chamber inflammation (P > 0.05) or adnexal inflammation (P > 0.05). Pain perception was less in the subjects in Group 1 as compared to subjects in Group 2, but was not statistically significant (P > 0.05).

CONCLUSION

Postoperative topical nepafenac was non-inferior to prednisolone acetate in reducing postoperative ocular inflammation in eyes undergoing TSV.

Role of topical nepafenac in prevention and treatment of macular edema after vitreoretinal surgery

PURPOSE

To evaluate the effects of topical nepafenac in patients undergoing vitreoretinal surgery.

METHODS

One hundred and twenty eyes of 120 patients undergoing vitreoretinal surgery were randomized to receive either topical nepafenac 0.1% (60 eyes) or placebo (60 eyes) in this investigator-masked, randomized, comparative case series. Eyes were evaluated for Day 1 postoperative inflammation and 2-, 4-, 6-, and 8-week postoperative retinal thickness and best-corrected visual acuity.

RESULTS

Mean Day 1 inflammation grades of 0.95 ± 0.6 and 1.78 ± 0.7 were noted in patients taking nepafenac and placebo, respectively (P = 0.002). The nepafenac and placebo groups had mean central macular subfield thickness of 228.44 ± 29.27 μm and 236.21 ± 29.44 μm at 4 weeks (P = 0.172) and 205.35 ± 25.25 μm and 205.37 ± 24.90 μm at 8 weeks (P = 0.971), respectively. At 1 month, there was no statistically significant difference in the mean visual acuity between the nepafenac group (0.55 ± 0.16 decimal units) and placebo group (0.52 ± 0.17 decimal units).

CONCLUSION

Topical nepafenac was safe and reduced postoperative pain and inflammation in patients undergoing vitreoretinal surgery. However, its effect on reducing postoperative macular edema and improving visual acuity as compared with that of the standard postvitrectomy therapeutic regimen was equivocal.

The efficacy of intravenous ketorolac for pain relief in single-stage adjustable strabismus surgery: a prospective, randomized, placebo-controlled trial

PURPOSE

To determine the efficacy of preoperative intravenous ketorolac in reducing intraoperative and postoperative pain and improving patient satisfaction in patients undergoing single-stage adjustable strabismus surgery.

METHODS

A prospective, randomized, placebo-controlled clinical trial was performed with 67 patients who underwent horizontal recti muscle surgery with adjustable sutures. The test group received intravenous ketorolac (60 mg) before surgery, and the control group received intravenous normal saline. Topical 0.5% proparacaine was administered to both groups during surgery. Vital signs including heart rate and blood pressure were recorded every 10 min throughout the surgery. The patients were asked to rate their maximum intraoperative and postoperative pain scores using a numerical pain rating scale. Patient satisfaction was also assessed using a five-point analogue scale.

RESULTS

The ketorolac-premedicated patients had less pain both during and after surgery (P = 0.033 and P = 0.024, respectively). There were no differences in vital signs during surgery and patient satisfaction between the two groups.

CONCLUSIONS

Intravenous ketorolac, when administered preoperatively for single-stage adjustable strabismus surgery under topical anaesthesia, was effective in reducing pain during and after surgery.

Nonsteroidal anti-inflammatory drugs in ophthalmology

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.

Topical Ketorolac 0.5% for Ocular Pain Relief During Scatter Laser Photocoagulation with 532 nm Green Laser

PURPOSE

The aim of this study was to evaluate the analgesic effect of topical ketorolac tromethamine 0.5% during scatter laser photocoagulation procedure in proliferative diabetic retinopathy patients.

METHODS

60 eyes of 30 consecutive proliferative diabetic retinopathy patients were included to this prospective, randomized, double-masked, controlled study. One (1) h before laser treatment session, ketorolac tromethamine 0.5% was instilled to 1 eye and artificial tear drop to the fellow eye. Just after treatment, the patients were asked for the severity of pain in both eyes. Visual analog scale was used to assess the level of pain.

RESULTS

Mean pain level for placebo-instilled eyes was 4.88+/-2.56 and ketorolac instilled eyes were 4.45+/-2.25. There was no significant difference for pain levels between placebo and ketorolac-instilled eyes (P=0.29).

CONCLUSIONS

Topical ketorolac tromethamine usage is no more effective than artificial tears for pain relief during posterior segment laser procedures in proliferative diabetic retinopathy patients.

Toxic keratolysis from combined use of nonsteroid anti-inflammatory drugs and topical steroids following vitreoretinal surgery

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.