Analgesic effects of tramadol during panretinal photocoagulation

A Comprehensive Meta-Analysis on the Role of Analgesics and Anti-Inflammatories in Pan-Retinal Photocoagulation

PURPOSE

Pan-retinal photocoagulation (PRP) is the mainstay of treatment for proliferative diabetic retinopathy (PDR), reducing the risk of severe vision loss. Pain poses a potential obstacle to effective laser delivery and patient compliance. Therefore, implementing pain relief strategies can enhance both treatment efficacy and patient comfort.

DESIGN

A systematic review and meta-analysis.

METHODS

We conducted a systematic review and meta-analysis according to PRISMA guidelines. The PubMed, Embase and Cochrane Central Register of Controlled Trials databases were searched for randomized controlled trials (RCTs) that enrolled patients undergoing PRP due to DR and compared analgesics or non-steroidal anti-inflammatory drugs (NSAID) to placebo. Pain was evaluated with the visual analogue scale. The version 2 of the Cochrane Collaboration's Risk of Bias in Randomized Controlled Trials tool and its version for crossover trials were used to assess the risk of bias. The Grading of Recommendations, Assessment, Development, and Evaluation tool was used to measure the certainty of evidence.

RESULTS

A total of 13 studies were included, comprising 1404 eyes from RCTs, nine of which were crossover. Patients who were administered analgesia reported a significantly lower pain sensitivity compared to those who received placebo (Standardized mean difference [SMD] -0.38; 95% confidence interval [CI] -0.58, -0.17; P < .01; I2 = 69%). Subgroup analysis of systemic administration of analgesics/NSAIDs (metamizole, Entonox, acetaminophen, ibuprofen, caffeine, mefenamic acid, intramuscular ketorolac tromethamine, and potassium diclofenac) also showed a statistically significant reduction in pain when compared to placebo (SMD -0.28; 95% CI -0.50, -0.07; P < .01; I2 = 43%). Exclusive eye drops administration (ketorolac tromethamine 0.5% and sodium diclofenac 0.1%) also showed a significant difference in pain sensitivity (SMD -0.46; 95% CI -0.88, -0.05; I2 = 83%), however with a more significant heterogeneity.

CONCLUSIONS

The results of this meta-analysis including over 1000 patients demonstrated that the use of analgesics significantly reduced pain sensitivity during PRP, and systemic analgesia is potentially better than topical administration when compared to placebo.

Pain Management Strategies before Pan-Retinal Photocoagulation for Diabetic Retinopathy: A Systematic Review

Purpose

This systematic review aims to consolidate key findings regarding the efficacy of pain relief medications administered prior to pan-retinal photocoagulation (PRP) for diabetic retinopathy (DR).

Methods

A comprehensive search of major databases from 1993 to 2023 was conducted. Clinical trials comparing pain relief drugs before PRP in patients diagnosed with DR requiring PRP treatment were eligible for inclusion. The assessment of pain scores involved the use of various scales, such as the visual analog scale (VAS), numerical rating scale (NRS), verbal rating scale (VRS), and other ordinal pain scales. In addition, laser parameters were taken into consideration during the analysis.

Results

Twenty-two clinical trials from initial 150 studies were included in the review. Nine studies evaluated the pain relief effects of nonsteroidal anti-inflammatories NSAIDs (selective NSAID and nonselective NSAID), two studies compared the effects of opioids (conventional opioids and atypical opioids), and eleven studies investigated the effects of benzodiazepines, lidocaine, and other sedatives.

Conclusion

This review synthesizes findings from multiple studies reporting pain as an adverse outcome of PRP in patients with advanced DR. Based on the evidence from reviewed clinical trials, the administration of lidocaine 2% via transconjunctival, retrobulbar, or peribulbar block along with specific NSAIDs, such as topical ketorolac administrated 24 hours before treatment or oral diclofenac potassium (50 mg) prior to PRP, demonstrated beneficial effects among patients with DR.

Patients' Preference Regarding Laser Photocoagulation or Cryoretinopexy for the Treatment of Retinal Pathology

Purpose:

High-risk peripheral retinal pathology can be prophylactically treated with both laser photocoagulation (laser) and cryoretinopexy (cryopexy). We sought to identify a possible preference by patients toward one modality and any underlying association.

Methods:

A single-center survey was conducted of patients with peripheral retinal pathology who received both laser and cryopexy at Associated Retinal Consultants (Royal Oak, Michigan). The main outcome measure was the preferred treatment modality.

Results:

Patients reported more pain after cryopexy (46%) than laser (11%). Most patients felt it was easier to recover from laser (52%) than cryopexy (13%). Overall, patients preferred laser (60%) to cryopexy (25%), with a minority (15%) having no preference. There was a negative relationship between a patient’s likelihood of preferring cryopexy and the number of applications ( P = .009).

Conclusions:

Most patients preferred laser (60%) to cryopexy. If cryopexy is performed, minimizing the number of freezes may improve the patient’s experience and recovery.

Comparison of Pain Scores Among Patients Undergoing Conventional and Novel Panretinal Photocoagulation for Diabetic Retinopathy: A Systematic Review

PURPOSE

To summarize key findings from a systematic review focusing on pain as an adverse outcome of panretinal photocoagulation (PRP) among patients with diabetic retinopathy.

DESIGN

Systematic review.

METHODS

We systematically searched articles in major databases from July to September 2020. Studies that compared pain outcomes of PRP among diabetic patients who underwent conventional single-spot laser (SSL), conventional multi-spot laser (MSL), and/or novel navigated laser (NNL) were included. The Cochrane RoB 2 tool and ROBINS-I tool were used to evaluate the risk of bias of the included randomized controlled trials (RCTs) and controlled clinical trials (CCTs), respectively.

RESULTS

We included 13 RCTs and 4 CCTs. Thirteen studies were included for Comparison 1 (Conventional SSL versus Conventional MSL), 3 studies were included for Comparison 2 (NNL versus Conventional MSL), and 3 studies were included for Comparison 3 (NNL versus Conventional SSL). A total of 783 patients and 1961 eyes were included in this review. The review showed that NNL yielded the lowest pain scores, followed by conventional MSL, then by conventional SSL.

CONCLUSION

This review summarizes findings of multiple studies that reported pain as an adverse outcome of PRP among patients with advanced diabetic retinopathy. Data from RCTs with mostly some concerns for bias (RoB 2 tool) and CCTs with mostly moderate risk of bias (ROBINS-I tool) show benefit of using MSL over SSL, and NNL over conventional systems for PRP in diabetic retinopathy, considering pain as the primary outcome.

Pain score of patients undergoing single spot, short pulse laser versus conventional laser for diabetic retinopathy

BACKGROUND

To compare pain score of single spot short duration time (20 milliseconds) panretinal photocoagulation (PRP) with conventional (100 milliseconds) PRP in diabetic retinopathy.

METHODS

Sixty-six eyes from 33 patients with symmetrical severe non-proliferative diabetic retinopathy (non-PDR) or proliferative diabetic retinopathy (PDR) were enrolled in this prospective randomized controlled trial. One eye of each patient was randomized to undergo conventional and the other eye to undergo short time PRP. Spot size of 200 μm was used in both laser types, and energy was adjusted to achieve moderate burn on the retina. Patients were asked to mark the level of pain felt during the PRP session for each eye on the visual analog scale (VAS) and were examined at 1 week, and at 1, 2, 4 and 6 months.

RESULTS

Sixteen women and 17 men with mean age 58.9 ± 7.8 years were evaluated. The conventional method required a mean power of 273 ± 107 mW, whereas the short duration method needed 721 ± 406 mW (P = 0.001). An average of 1,218 ± 441 spots were delivered with the conventional method and an average of 2,125 ± 503 spots were required with the short duration method (P = 0.001). Average pain score was 7.5 ± 1.14 in conventional group and 1.75 ± 0.87 in the short duration group (P = 0.001). At 1 week, 1 month, and 4 months following PRP, the mean changes of central macular thickness (CMT) from baseline in the conventional group remained 29.2 μm (P = 0.008), 40.0 μm (P = 0.001), and 40.2 μm (P = 0.007) greater than the changes in CMT for short time group.

CONCLUSION

Patient acceptance of short time single spot PRP was high, and well-tolerated in a single session by all patients. Moreover, this method is significantly less painful than but just as effective as conventional laser during 6 months of follow-up. The CMT change was more following conventional laser than short time laser.

Comparison of the analgesic effects of oral tramadol and naproxen sodium on pain relief during IUD insertion

OBJECTIVE

To compare the analgesic efficacy of oral tramadol and naproxen sodium on pain during insertion of an intrauterine device (IUD).

DESIGN

Randomized, double-blinded, clinical trial (Canadian Task Force classification I).

SETTING

University-affiliated hospital. Single-center.

PATIENTS

One hundred three patients scheduled for insertion of an IUD.

INTERVENTIONS

Patients were randomly assigned to receive oral tramadol 50 mg capsules (n = 35) or naproxen sodium 550 mg tablets (n = 34) or placebo (n = 34) 1 hour before insertion of the IUD. After insertion of the IUD, pain intensity was evaluated using a visual analog scale (VAS, 0-10). Adverse effects, patient satisfaction with the medication, and preference for using it during future insertions were also recorded.

MEASUREMENTS AND MAIN RESULTS

The VAS scores were significantly different during IUD insertion among the 3 groups (p = .001). Pain scores in the tramadol group were significantly lower than in the naproxen group (p = .003), and the scores in the naproxen group was significantly lower than in the control group (p = .001). Patient satisfaction with the medication and preference for its future use were significantly lower in the control group than in the other 2 groups (p = .001).

CONCLUSION

Prophylactic analgesia using 50 mg tramadol and 550 mg naproxen, delivered orally, can be used to relieve pain during IUD insertion. However, tramadol capsules were found to be more effective than naproxen tablets.