Topical Bromfenac 0.09% vs Ketorolac 0.4% for the Control of Pain, Photophobia, and Discomfort Following PRK

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Assessment of Factors Associated With Postoperative Pain After Photorefractive Keratectomy

PURPOSE

To define the factors that affect patient's self-assessed postoperative pain after photorefractive keratectomy (PRK).

METHODS

Patients who underwent PRK in 2016 were evaluated. Anonymized data collected included patient gender, age, and season at the time of surgery, ablation depth, surgeon status (attending vs. resident), topical tetracaine use, and subjective pain scores at postoperative days (PODs) 1 and 7. Average pain scores and amount of pain medication taken were analyzed for each of the previously mentioned variables.

RESULTS

Overall, 231 patients who underwent PRK were analyzed. The mean pain score and SD were 0.78 ± 1.87 on POD 1 and 0.03 ± 0.37 by POD 7. Patients who used topical tetracaine reported significantly higher pain on POD 1 and 7 compared with patients who did not use tetracaine (P < 0.001 and P = 0.038, respectively). No significant differences in pain scores were seen based on surgeon status, ablation depth, gender, and season. Patients who used topical tetracaine took a higher amount of oral pain medication (9.44 ± 6.01) compared with those who did not (7.02 ± 4.71) (P = 0.022).

CONCLUSIONS

Postoperative pain was significantly elevated in patients who used tetracaine on POD 1 and POD 7. These patients were also more likely to take oral pain medication than those who did not use topical tetracaine. Surgeon status, season, gender, and ablation depth showed no significant differences in subjective pain scores. Oral pain medication should be evaluated to assess efficacy and safety in inhibiting ocular pain after PRK.

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

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

Ascorbic acid versus placebo in postoperative lid edema postphotorefractive keratectomy: A double-masked, randomized, prospective study

INTRODUCTION

Photorefractive keratectomy (PRK) is a proper type of refractive surgery used to remodel corneal stroma to compensate refractive errors. Corneal haze was reported as one of the side effects in several studies. This study was conducted for investigation of the effect of preventive effect of Vitamin C on eyelid edema, corneal haze, corneal epithelial healing, mitigation of pain, and epiphora.

MATERIALS AND METHODS

This study has been performed as a double-blind clinical trial on 51 patients who underwent PRK surgery. The patients were randomly divided into two groups as follows: case group who received oral ascorbic acid 250 mg once daily for 7 days and control group that took placebo 3 days before and 4 days after the surgical operation. The patients underwent a surgical operation on day 0. Then, the following factors were evaluated as the main outcome: postoperative lid edema, pain, corneal haze, and corneal reepithelialization.

RESULTS

The mean age of the patients was 28.52 ± 8.05 years. There was no statistically significant difference in the primary outcome of the subjective pain scores along with corneal haze and corneal reepithelialization between the treatment and placebo groups at any point during the postoperative period; however, there was a statistically significant difference and trend for lower lid edema in the ascorbic acids group on postoperative day 1 (P < 0.05).

CONCLUSION

This study demonstrates that ascorbic acid may provide an alternative or add-on option for lid edema relief after PRK.

Pain perception description after advanced surface ablation

Purpose

The objective of this study was to characterize the evolution of ocular pain after advanced surface ablation (ASA) to improve strategies in postoperative pain management.

Methods

This was a multicenter, prospective, descriptive, cohort study. The inclusion criteria were healthy individuals ≥18 years old receiving bilateral alcohol-assisted surface ablation with epithelial removal. Pain intensity was evaluated with the visual analog scale (VAS) and the numeric pain rating scale before and after surgery. Comorbidities (photophobia, burning, tearing, and foreign body sensation) and Hospital Anxiety and Depression (HAD) questionnaire were evaluated before and at 6 hours after surgery. Postoperative treatments included cold patch, topical cold antibiotics, topical steroids, and benzodiazepines.

Results

Thirty-two consecutive patients having similar profiles of postoperative pain evolution were included. At 0.5 hour after ASA, the pain score by VAS was 37±20 mm, and the maximum pain, 61±31 mm, occurred at 24 hours. Afterward, it decreased progressively until 72 hours after surgery (19±20 mm). Most patients (81%) scored >60 mm, and 44% required rescue medication. Among the comorbidities, all patients had photophobia and 84% had burning sensation. At 6 hours, the HAD score was 5.4±3.9, within the range of values considered as normal.

Conclusion

Postoperative acute ocular pain after ASA showed a characteristic evolution over time. Recognition of the pattern could be important for improving the acceptance of ASA and for improving strategies in pain management in the postoperative period.

Analgesic Effect of Topical Sodium Diclofenac before Retinal Photocoagulation for Diabetic Retinopathy: A Randomized Double-masked Placebo-controlled Intraindividual Crossover Clinical Trial

PURPOSE

To evaluate the analgesic effect of topical sodium diclofenac 0.1% before retinal laser photocoagulation for diabetic retinopathy.

METHODS

Diabetic patients who were candidates for peripheral laser photocoagulation were included in a randomized, placebo-controlled, intraindividual, two-period, and crossover clinical trial. At the first session and based on randomization, one eye received topical sodium diclofenac 0.1% and the other eye received an artificial tear drop (as placebo) three times before laser treatment. At the second session, eyes were given the alternate drug. Patients scored their pain using visual analogue scale (max, 10 cm) at both sessions. Patients and the surgeon were blinded to the drops given. Difference of pain level was the main outcome measure.

RESULTS

A total of 200 eyes of 100 patients were enrolled. Both treatments were matched regarding the applied laser. Pain sensation based on visual analogue scale was 5.6 ± 3.0 in the treated group and 5.5 ± 3.0 in the control group. The calculated treatment effect was 0.15 (95% confidence interval, -0.27 to 0.58; p = 0.486). The estimated period effect was 0.24 (p = 0.530) and the carryover effect was not significant (p = 0.283).

CONCLUSIONS

Pretreatment with topical sodium diclofenac 0.1% does not have any analgesic effect during peripheral retinal laser photocoagulation in diabetic patients.

Ocular pain and discomfort after advanced surface ablation: an ignored complaint

Purpose

Laser vision correction is one of the most commonly performed elective surgical procedures in ophthalmology. Generally, discomfort besides pain (photophobia, burning sensation, tearing, and foreign body sensation) after these procedures is not taken into consideration in the clinical practice. The objective is to provide data on these symptoms and their relevance after advanced surface ablation (ASA).

Methods

Single-center survey study based on a structured questionnaire relative to the patients’ perceived symptoms after ASA. Inclusion criteria were: ≥18 years old, no ocular disease, with myopia (0.75 to 9 D) or hyperopia (0.25 to 5 D) with or without astigmatism, receiving ASA on at least one eye. All procedures were performed by the same surgeon. A descriptive analysis was performed.

Results

Seventy-three consecutive patients (34 men and 39 women) were included in the study. The median (range) of age was 33 (19–64) years. Sixty-nine patients had surgery done on both eyes. Postoperative pain was the most frequent comorbidity (97% [95% confidence interval {CI}: 90–100]) with a median (range) of intensity (verbal numerical rating scale) score of 7 (2–10). Photophobia: 85% (95% CI: 75–92); burning sensation: 62% (95% CI: 50–73); tearing: 59% (95% CI: 47–70); and foreign body sensation: 48% (95% CI: 36–60) were also prevalent postoperative symptoms. Pain during ASA was reported for 44% (95% CI: 32–56) of patients.

Conclusion

Comorbidities such as pain, photophobia, burning sensation, tearing, and foreign body sensation are prevalent after ASA procedure. Postoperative pain should be taken into consideration due to its prevalence and intensity. A new and more efficient postoperative analgesic protocol should be established.

Comparison of the effect of cycloplegic versus NSAID eye drops on pain after photorefractive keratectomy

PURPOSE

To compare the effect of Homatropine and Diclofenac eye drops for reducing pain after photorefractive keratectomy (PRK).

METHODS

This randomized, double-masked, interventional study included 32 patients (64 eyes) who underwent bilateral PRK. After operation, patients received Homatropine eye drops in one eye and Diclofenac eye drops in the fellow eye for 48 h. The level of pain was evaluated using visual analogue scale (VAS), verbal rating scale (VRS), and pain rating index (PRI) at 0.5, 24, and 48 h after operation.

RESULTS

The level of pain was statistically similar between the two eyes half an hour after operation; however, Diclofenac eyes had significantly less pain 24 h after operation (1.7 ± 1.4 vs 5.8 ± 2.1, P < 0.001 for VAS, 0.6 ± 0.6 vs 2.4 ± 1.1, P < 0.001 for VRS, and 3.4 ± 3.4 vs 12.0 ± 6.9, P < 0.001 for PRI, respectively). Also, 48 h after surgery, the pain scores were less in the Diclofenac eyes (1.6 ± 1.8 vs 3.4 ± 2.8, P < 0.001 for VAS, 0.6 ± 0.6 vs 1.2 ± 0.9, P < 0.001 for VRS, and 3.3 ± 3.7 vs 6.5 ± 6.2, P < 0.001 for PRI). No case with delayed epithelial healing in both groups was observed.

CONCLUSION

The effect of Homatropine seems to be lower compared to Diclofenac for reducing pain after photorefractive keratectomy.

Topical bromfenac for post-cataract extraction: A systematic review and pooled analysis

Bromfenac, a promising ophthalmic non-steroidal anti-inflammatory drug, has been used once daily for postoperative ocular inflammation and pain with satisfying efficacy, however, no integrated conclusion on its safety in clinical settings has been drawn. The purpose of this pooled analysis is to investigate the safety and efficacy of once daily bromfenac for ocular inflammation and pain among patients after cataract extraction (CE). MEDLINE, PsycINFO, Scopus, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched from inception to September 2014. Randomized controlled trials (RCTs) that studied topical bromfenac after CE were analyzed. Included studies were systemically reviewed, and effects were summarized using odds ratio (OR) with suitable effect model. Four RCTs involving 2294 participants were included. Topical bromfenac significantly increased the proportion of cleared ocular inflammation (OR, 2.37; 95% confidence interval [CI], 1.83–3.07; P <0.00001), ocular pain free (OR, 5.14; 95% CI, 4.07–6.49; P <0.00001), and decreased risk of overall adverse events (OR, 0.47; 95% CI, 0.38–0.58; P <0.00001). Bromfenac has been shown to be a safe and effective treatment for postoperative pain and inflammation in subjects undergoing CE. This is evidenced by the lower incidence of adverse events and the low scores for ocular pain and inflammation across multiple RCTs. However, demographics, co-morbidities of study participants, and the amount of co-medication were not reported, these possible sources of heterogeneity should be examined in future clinical trials.

Corneal Regeneration After Photorefractive Keratectomy: A Review

Photorefractive keratectomy (PRK) remodels corneal stroma to compensate refractive errors. The removal of epithelium and the ablation of stroma provoke the disruption of corneal nerves and a release of several peptides from tears, epithelium, stroma and nerves. A myriad of cytokines, growth factors, and matrix metalloproteases participate in the process of corneal wound healing. Their balance will determine if reepithelization and stromal remodeling are appropriate. The final aim is to achieve corneal transparency for restoring corneal function, and a proper visual quality. Therefore, wound-healing response is critical for a successful refractive surgery. Our goal is to provide an overview into how corneal wounding develops following PRK. We will also review the influence of intraoperative application of mitomycin C, bandage contact lenses, anti-inflammatory and other drugs in preventing corneal haze and post-PRK pain.

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

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

FINANCIAL DISCLOSURE

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

Effect of Homatropine eye drops on pain after photorefractive keratectomy: A pilot study

PURPOSE

To assess the effect of homatropine eye drops on pain after photorefractive keratectomy (PRK).

METHODS

This randomized, double masked, interventional study included 15 patients (30 eyes) who underwent bilateral PRK. After operation, patients received homatropine eye drops, 4 times daily in only one eye (homatropine eye). The level of pain was evaluated using visual analogue scale (VAS), verbal rating scale (VRS) and pain rating index (PRI) at 0.5, 24 and 48 h after operation.

RESULTS

The level of pain was statistically similar between the two eyes half an hour after operation, however, homatropine eyes had significantly less pain 24 h after operation compared to fellow eyes (2.5 ± 1.9 vs 5.3 ± 2.5, P = 0.004 for VAS, 2.0 ± 1.2 vs 3.2 ± 0.9, P = 0.023 for VRS, and 9.4 ± 5.7 vs 16.0 ± 9.0, P = 0.031 for PRI). Also, 48 h after surgery, the pain scales were less in the homatropine eyes (2.3 ± 1.7 vs 4.0 ± 2.1, P = 0.014 for VAS, 1.6 ± 1.0 vs 2.5 ± 1.0, P = 0.038 for VRS, and 6.8 ± 5.7 vs 12.0 ± 8.9, P = 0.005 for PRI). No delayed epithelial healing was observed.

CONCLUSION

Homatropine eye drops may be useful for reducing pain after Photorefractive keratectomy.

Pain and Its Determinants in Photorefractive Keratectomy

PURPOSE

To assess the determinants of early postoperative pain in photorefractive keratectomy.

DESIGN

A prospective cross-sectional study.

METHODS

One hundred and four myopic-astigmatic patients undergoing bilateral standard photorefractive keratectomy were evaluated for early postoperative pain severity. On day 1 postoperatively, the level of pain experienced was reported by the patient on a visual analog scale of 0 to 10. At the preoperative interview, data were collected on clinical, demographic, and social characteristics to find potential pain determinants.

RESULTS

The median reported pain level was 3. About 20% of subjects reported a pain score of 6 or higher, and 2.9% (6 eyes of 4 patients) reported the highest pain score. The presence of external eye inflammatory signs was associated with higher levels of pain (P < 0.001). Patients with a higher body mass index reported more severe pain (P = 0.006). An inverse association was found between pain and harmful lifestyle choices (P = 0.008). Demographic characteristics, history of contact lens wear, history of major operation, past experience of severe pain, knowledge about the operation's adverse effects, preoperative insomnia, preoperative anxiety, operative factors, and refractive indices were not related to the severity of pain experienced (all P > 0.05).

CONCLUSIONS

The association of pain with ocular surface inflammation suggests that inflammatory processes have a role in early postoperative pain, supporting the use of anti-inflammatory agents for pain management. Prescription of weight-adjusted dosages of analgesics is recommended on the basis of the association between severity of postoperative pain and body mass index.

Update on twice-daily bromfenac sodium sesquihydrate to treat postoperative ocular inflammation following cataract extraction

Ophthalmic bromfenac sodium sesquihydrate is a topically applied selective cyclooxygenase (COX)-2 inhibitor. It is similar to amfenac, except for a bromine atom at the C(4) of the benzoyl ring position, which markedly affects its in vitro and in vivo potency, extends the duration of anti-inflammatory activity, and enhances its inhibitory effect on COX-2 absorption across the cornea and penetration into ocular tissues. The United States Food and Drug Administration approved bromfenac in 2005 for the treatment of postoperative inflammation and the reduction of ocular pain in patients who have undergone cataract surgery. Nonsteroidal anti-inflammatory drugs (NSAIDs), and among them bromfenac, could be even more effective than steroids at reestablishing the blood-aqueous barrier, as revealed by flare on slit-lamp examination and as quantitatively measured using ocular fluorophotometry. Similar to other NSAIDs, it has a role in inhibiting intraoperative miosis during cataract surgery. However, bromfenac also seems to be useful in other situations, such as refractive surgery, allergic conjunctivitis (not useful in dry eye), choroidal neovascularization, and even ocular oncology. No reports of systemic toxicity have been published and bromfenac has good topical tolerance with a low incidence of adverse effects.

Prostaglandin E2 inhibition of ketorolac 0.45%, bromfenac 0.09%, and nepafenac 0.1% in patients undergoing phacoemulsification

INTRODUCTION

We compared the prostaglandin E(2) (PGE(2)) inhibition of three topical nonsteroidal antiinflammatory drugs (NSAIDs): ketorolac 0.45%, bromfenac 0.09%, and nepafenac 0.1% at peak dosing levels in patients previously scheduled to undergo phacoemulsification.

METHODS

This was a single-center, double-masked observational study of 121 patients randomized to one of three NSAID treatment arms. Patients were instructed to take the NSAID per on-label dosing (twice daily [b.i.d.] for ketorolac 0.45% and bromfenac 0.09%, three times a day [t.i.d.] for nepafenac 0.1%) for 1 day before surgery, and were to instill one drop the morning of surgery. Each patient received an additional four doses 1 hour prior to undergoing phacoemulsification. After completion of the paracentesis site with a super blade, aqueous humor (0.15 mL) was collected through the peripheral clear cornea with a 30 G needle attached to a tuberculin (TB) syringe. Aqueous humor samples were stored at -40°C prior to analysis, and diluted 1:10 with diluent. Assays were conducted on multiple plates in duplicate (seven standards per plate).

RESULTS

The mean (±SD) PGE(2) concentrations were 224.8±164.87 pg/mL for ketorolac 0.45% (n=42), 288.7±226.05 pg/mL for bromfenac 0.09% (n=41), and 320.4±205.6 pg/mL for nepafenac 0.1% (n=38). The difference between ketorolac 0.45% and nepafenac 0.1% was statistically significant (P=0.025). The difference between bromfenac 0.09% and nepafenac 0.1% was not significantly different (P=0.516).

CONCLUSIONS

Ketorolac 0.45% achieved the greatest inhibition of PGE(2) compared to nepafenac 0.1% and bromfenac 0.09%. Ketorolac 0.45% may be more efficacious at controlling inflammation at the time of cataract surgery versus nepafenac 0.1% and bromfenac 0.09%.

Evaluation of analgesic efficacy of bromfenac sodium ophthalmic solution 0.09% versus ketorolac tromethamine ophthalmic solution 0.5% following LASEK or Epi-LASIK

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.