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NSAID regimen important in perioperative care of laser surface ablation patients
Experts in the field shared their drug choices and dosing regimens for pain control.
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Nonsteroidal anti-inflammatory drugs play a prominent role in controlling pain for patients undergoing refractive surgery with surface ablation procedures, experts say.
“I’ve found them to be extremely helpful,” said Daniel S. Durrie, MD. “I have used almost all of the nonsteroidals starting with Voltaren (diclofenac, Novartis) and Acular (ketorolac tromethamine 0.5%, Allergan). I have used Acular LS (ketorolac tromethamine 0.4%, Allergan) and then, over the last year, have been using Nevanac (nepafenac sodium, Alcon), and I have also used Xibrom (bromfenac, Ista).”
In interviews with Ocular Surgery News, Dr. Durrie and other refractive surgeons who use surface ablation extensively discussed their preferences among the available topical ophthalmic NSAIDs.
Surgeons we interviewed said that in their clinical experience, with the regimens they use, the currently available topical ophthalmic NSAIDs have not been associated with delays in epithelial healing after surface ablation.
 Daniel S. Durrie |
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This article discusses off-label uses of some drugs. Acular LS is approved by the U.S. Food and Drug Administration for control of pain after PRK. Xibrom and Nevanac are both used off-label for this indication.
Voltaren Ophtha is approved for pain control and photophobia after corneal refractive surgery, but no surgeons interviewed for this article said they are currently using it. In the 2005 survey by David V. Leaming, MD, of members of the American Society of Cataract and Refractive Surgery, none of the high-volume refractive surgeons responding to the survey listed diclofenac as their preferred anti-inflammatory for refractive surgery. It is not discussed further in this article.
Acular LS
Eric D. Donnenfeld, MD, said he uses Allergan’s Acular LS preoperatively, intraoperatively and postoperatively in patients undergoing surface ablation.
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Eric D. Donnenfeld |
“When I’m doing surface ablation, I pretreat for 1 day with Acular LS four times a day,” Dr. Donnenfeld said, “and then I use the drops intraoperatively.”
He explained that using an NSAID preoperatively takes advantage of the pain prevention mechanisms of the drug. If the drug is not applied until after the procedure, he said, prostaglandins that are inhibited by NSAIDs are already present.
Dr. Donnenfeld said he also soaks a bandage contact lens in Acular LS and applies it after the ablation, and he instructs patients to administer drops of the NSAID four times a day for 3 to 4 days until the epithelium is healed.
“By soaking the contact lens in the Acular LS, I get a default nonsteroidal,” he said. “I’ve been doing this now for about 3 years, and I find that’s the single most important aspect of controlling pain.”
Dr. Donnenfeld emphasized the he has not seen a delay in healing with the use of Acular LS, but he said he would not recommend this method with other NSAIDs unless they have been tested in this capacity.
William B. Trattler, MD, and Marguerite B. McDonald, MD, FACS, said they prescribe the drug for postoperative use in their surface ablation patients.
Dr. Trattler said he gives patients Acular LS postoperatively for 5 days in about 85% of his cases. Dr. McDonald prescribes Acular LS postoperatively, one drop four times a day for 3 days, starting on the day of surgery. This is one part of her extensive regimen of pain control, which is described later in this article and is detailed in the box below.
In the past, Dr. McDonald said, she prescribed the NSAID on an as-needed basis, but now she specifies how it should be used.
“They just must simply take it,” she said. “I find that it works better because people have a tendency to wait until they really feel tremendous pain to take a pain medication, and it’s easier to blunt or prevent the pain before it gets to be out of control.”
Nevanac
Dr. Durrie said he uses Alcon’s Nevanac postoperatively to control pain in his surface ablation patients.
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Marguerite B. McDonald |
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“I do not use Nevanac preop, and I do not use it in the operating room,” he emphasized. Patients are instructed to use the NSAID up to four times a day for 48 hours postoperatively.
“That’s the same way I’ve been using nonsteroidals for the last 10 years,” he said. “I haven’t done anything new, and I’ve found them to be extremely valuable.”
Because Nevanac is not specifically FDA-approved for use after surface ablation, Dr. Durrie has reviewed the results in his own patients in whom Nevanac was used.
In 500 eyes with his current prescribing regimen, which includes Nevanac, Dr. Durrie found 10 eyes that took between 5 and 7 days to heal and one that took more than 7 days.
“That’s less than 0.5% of the patients we did, so it’s a small percentage and nothing that’s out of the norm for surface ablation,” he said.
“We haven’t had any haze development in any of them,” Dr. Durrie continued. “The main reason I did these studies was to see if there is any reason I shouldn’t be using nepafenac. It seems to be a little bit better pain control and the same in the wound healing.”
A study presented by Charles Reilly, MD, at the American Academy of Ophthalmology meeting in Las Vegas found no difference in healing time and no clinically meaningful difference in epithelial defects between nepafenac and placebo (balanced salt solution).
“I was pleasantly surprised to find that there was not really much of a problem in short term use, which is how I envision most people use the medication in the setting of surface refractive surgery,” Dr. Reilly told OSN. “Used appropriately, topical nepafenac is a nice adjunct to refractive surgery.”
There were also no adverse effects or evidence of corneal toxicity with nepafenac, Dr. Reilly concluded.
“I would not have any issues with someone who would want to use nepafenac as part of their routine postoperative regimen if they followed the guidelines that we did in our study in limiting the use to three times a day for the first 2 days following surgery,” he told OSN.
Dr. Reilly said, unlike Dr. Donnenfeld, that he does not give an NSAID preoperatively.
“We felt pretty strongly that there’s no advantage to placing the nonsteroidal prior to surgery since the patients already have topical anesthesia on board using either tetracaine or proparacaine. We figured after the surgery was the time when the pain would start, so that’s the appropriate time to start the nonsteroidal.”
Dr. Donnenfeld noted that he did not recommend using his contact-lens soaking technique with nepafenac.
“It’s not recommended to put Nevanac on until after the contact lens is placed because of problems with re-epithelialization and haze,” he said.
Xibrom
Ista Pharmaceuticals’ Xibrom, or bromfenac, is another NSAID used off-label for pain control in surface ablation.
Barry Schechter, MD, said he feels bromfenac is “far superior to the others.” He prescribes it for patients undergoing surface ablation, and for patients undergoing pterygium surgery and other surgeries that may affect the ocular surface. In addition, he uses it to control pain in patients with herpetic or bacterial infectious keratitis.
“The affinity of Xibrom for the COX-2 enzyme is several logarithmic units above that of the other commercially available NSAIDs,” Dr. Schechter said.
H.L. Rick Milne, MD, also said he prescribes bromfenac in surface ablation patients. His refractive surgical practice is 100% surface ablation, he said.
“Its efficacy … and lack of stinging upon instillation make it an excellent choice for NSAID use,” he told OSN.
Given four times a day beginning the day of surgery, Xibrom does not impede healing, Dr. Milne said.
“This is by far the most potent blocker of COX-2 of all the ones we have,” Dr. Milne said. “It’s significantly stronger than Nevanac, Acular or Voltaren as far as its ability to block.”
Dr. Trattler agreed that Xibrom can be effective in controlling pain.
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Surgeons extensive regimen combines many aspects of pain control
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Additional pain control
Surgeons interviewed for this article said NSAIDs are only part of their pain-control regimens, which range from simple to elaborate.
“There’s a lot of pain, and you need a lot of medicine to control that much pain,” Dr. McDonald said.
Dr. Donnenfeld said he gives patients chilled artificial tears postop, and he prescribes an “escape medicine,” such as hydrocodone. He added that only about 10% need the oral pain medication.
In addition to topical nepafenac, Dr. Durrie also prescribes the topical steroid Pred Forte (prednisolone acetate ophthalmic suspension 1%, Allergan) four times a day for the first week.
Dr. Milne’s pain regimen, in addition to bromfenac, includes Lyrica (pregabalin, Pfizer) or Neurontin (gabapentin, Pfizer), rosarin and Mepergan (promethazine/meperidine, Wyeth) for breakthrough pain.
“I do 100% surface ablation now, and this is one of the reasons I can go there,” Dr. Milne said. “This combination really works, and it takes away one of the big needs for LASIK.”
Dr. McDonald has perhaps the most elaborate pain-control regimen, which has drawn the attention of many of her colleagues because of its success.
“The regimen is very elaborate and pretty intense, but it works well,” Dr. McDonald said. (See sidebar for details of the regimen.)
When to stop
Those interviewed for this article agreed that if the patient does not heal within a certain amount of time, NSAIDs should be discontinued.
“In the majority of cases, [NSAIDs] will not interfere with epithelial wound healing, but patients who have had surface ablation and have a contact lens on and have an open epithelial defect need to be followed very carefully,” Dr. Durrie said. “Our general rule is that patients should be totally epithelialized in 3 to 5 days.”
He added that if the epithelium has not completely regenerated by 7 days postop, there is a chance that the patient will develop haze.
Dr. Donnenfeld said, “If you have a patient who is not healing after PRK, the first thing you should do is stop the nonsteroidals.”
“I would look to improve any type of tear-film abnormalities to maximize healing,” he said. “Consider putting the patient on oral doxycycline, 100 mg twice a day, which has an anti-collagenase effect, improves tear quality and has been shown to be effective in preventing persistent epithelial defects.”
Dr. Trattler said surgeons should consider dry eye as the potential cause of delay in epithelial healing. If dry eye is to blame, punctal plugs or topical cyclosporine might be needed to speed healing.
For more information:
- Daniel S. Durrie, MD, can be reached at Durrie Vision, 5520 College Blvd., Suite 200, Overland Park, KS 66211; 913-491-3737; fax: 913-491-9650; e-mail: ddurrie@durrievision.com. Dr. Durrie is a paid consultant for Alcon.
- Eric D. Donnenfeld, MD, is a cornea specialist in private practice at Ophthalmic Consultants of Long Island and co-chairman of Cornea and External Disease at Manhattan Eye, Ear and Throat Hospital. He can be reached at Ryan Medical Arts Building, 2000 North Village Ave., Rockville Centre, NY 11570; 516-766-2519; fax: 516-766-3714; e-mail: eddoph@aol.com. Dr. Donnenfeld is a consultant for Alcon and Allergan and performs research for Ista Pharmaceuticals.
- William B. Trattler, MD, can be reached at the Center for Excellence in Eye Care, 8940 N. Kendall Drive, #400, Miami, FL 33176; 305-598-2020; fax: 305-274-0426; e-mail: wtrattler@earthlink.net. Dr. Trattler is an Allergan consultant and conducts research for Allergan and Ista.
- Marguerite B. McDonald, MD, FACS, can be reached at Ophthalmic Consultants of Long Island, 266 Merrick Road, Lynbrook, NY 11563; 516-593-7709; e-mail: margueritemcdmd@aol.com. Dr. McDonald is a consultant for Advanced Medical Optics and Allergan.
- Charles Reilly, MD, can be reached at 59th Medical Wing, 2200 Bergquist Drive, Suite. 1, Lackland AFB, TX 78236; 210-292-2010; e-mail: charles.reilly@lackland.af.mil. Ocular Surgery News was unable to determine whether Dr. Reilly has a direct financial interest in the products discussed in this article or if he is a paid consultant for any companies mentioned.
- Barry Schechter, MD, can be reached at Florida Eye Microsurgery Institute, 1717 Woolbright Road, Boynton Beach, FL 33436; 561-737-5500; e-mail: BDSCH77@aol.com. Dr. Schechter is a consultant for Ista pharmaceuticals, Allergan and Celgene Inc.
- H. L. Rick Milne, MD, can be reached at The Eye Center, 1655 Bernardin Ave., Suite 100, Columbia, SC 29204; 803-256-0641; e-mail: hmilne@aol.com. Ocular Surgery News was unable to determine whether Dr. Milne has a direct financial interest in the products discussed in this article or if he is a paid consultant for any companies mentioned.
- Alcon, maker of Nevanac, can be reached at 6201 South Freeway, Fort Worth, TX 76134; 817-293-0450; fax: 817-568-6142; Web site: www.alconlabs.com. Allergan, maker of Acular, can be reached at P.O. Box 19534, Irvine, CA 92623; 714-246-4500; fax: 714-246-4971; Web site: www.allergan.com. Ista Pharmaceuticals, maker of Xibrom, can be reached at 15295 Alton Parkway, Irvine, CA 92618; 949-788-6000; fax: 949-788-6010; Web site: www.istavision.com. Novartis International AG, maker of Voltaren Ophtha, can be reached at CH-4002 Basel, Switzerland; 41-61-324-1111; fax: 41-61-324 8001; Web site: www.novartis.com.
- Katrina Altersitz is an OSN Staff Writer who covers all aspects of ophthalmology.