Pain management in cataract and refractive surgery

ByHenry Perry, MD

Henry Perry, MD [photo]
Henry Perry, MD

When used in conjunction with contact lenses, NSAIDs result in faster recovery times for patients who had traumatic corneal abrasions.

One of the most significant challenges that ophthalmologists face when performing cataract surgery involves managing patient expectations. Patients are not concerned with phaco time, technique or technology, but rather intraoperative comfort and postoperative results. Most patients do not want stitches, pain or injections. In order to achieve better outcomes, I routinely use nonsteroidal anti-inflammatory drugs (NSAIDs) for my cataract surgery cases.

NSAIDs vs. corticosteroids

Several studies have been performed showing that NSAIDs reduce inflammation, pain and general discomfort after cataract surgery, including data from Kerry D. Solomon, MD, Robert W. Snyder, MD, PhD, and Calvin W. Roberts, MD.^1-3

Based on the information in these and other studies, I have completely switched from using corticosteroids alone and rely on the addition of topical NSAIDs. As a result, my patients have had whiter eyes and less inflammation after surgery and have expressed higher satisfaction 1 day postoperatively. I also like to involve my patients in their care by providing them with information on the studies on NSAIDs so that they feel more confident and comfortable going into surgery.

In addition to cataract surgery, I find that NSAIDs are also useful for reducing pain in refractive surgery. Many patients who undergo refractive surgery have blepharospasm that results in striae after LASIK. NSAIDs help to reduce this complication.⁴ Additionally, a longer acting NSAID will blunt the inflammatory and pain response for a longer period, which may be useful for postoperative recovery for LASIK.

Steroids affect postoperative results, but not patient comfort — they block inflammation, but do not have any significant effect on pain. NSAIDs, on the other hand, have an analgesic and anesthetic effect as well as being anti-inflammatory. The Food and Drug Administration has never approved corticosteroids for postoperative cataract surgery, although most surgeons have used them for this purpose.

I prefer not to use corticosteroids in certain patients because of their adverse effects, such as inhibition of epithelial healing and wound strengths, induction of ocular hypertension and the potentiation for secondary infections.⁵

NSAIDs to reduce inflammation, increase recovery times

After surgical trauma is induced, the inflammatory cascade begins. Phospholipase A2 acts on the phospholipids to create arachidonic acid, which is the primary mediator of inflammation in cataract surgery via its connection to the cyclooxygenase (COX) pathway, or COX-1 and COX-2. Leukotrienes are also important in terms of the cellular changes that are seen in the anterior chamber, but the cyclooxygenases are the main catalysts in the inflammation process because of prostaglandin release.

In my opinion, using NSAIDs 3 days preoperatively will reduce the amount of naturally produced prostaglandins in the iris, resulting in fewer problems with vascular permeability, less effect on the blood-aqueous barrier, less vasodilation and miosis and a decrease in IOP.

NSAIDs also may be useful in treating corneal abrasions. Eric D. Donnenfeld, MD, and colleagues and I performed a study on traumatic abrasions and the effect of NSAIDs. We found that, when used in conjunction with contact lenses, NSAIDs result in faster recovery times for patients who had traumatic corneal abrasions.⁶

Conclusion

In order to meet higher patient expectations following cataract and refractive surgery, I have switched from using corticosteroids alone to now using NSAIDs in combination to reduce inflammation, pain and discomfort postoperatively. NSAIDs block inflammation and ease patient discomfort, while steroids have no analgesic or anesthetic effect and a number of adverse effects. Using NSAIDs preoperatively will reduce prostaglandin response, resulting in subsequently fewer problems with vascular permeability, less effect on the blood-aqueous barrier, less vasodilation and miosis, and a decrease in IOP. NSAID use also results in faster recovery times for patients with traumatic corneal abrasions.

References

Solomon KD, Cheetham JK, DeGryse R, Brint SF, Rosenthal A. Topical ketorolac tromethamine 0.5% ophthalmic solution in ocular inflammation after cataract surgery. Ophthalmology. 2001;108(2):331-337.

Nichols J, Snyder RW. Topical nonsteroidal anti-inflammatory agents in ophthalmology. Curr Opin Ophthalmol. 1998;9(4):40-44.

Roberts CW, Brennan KM. A comparison of topical diclofenac with prednisolone for postcataract inflammation. Arch Ophthalmol. 1995;113:725-727.

Price FW, Price MO, Zeh W, Dobbins K. Pain reduction after laser in-situ keratomilieusis with ketorolac tromethamine ophthalmic solution 0.5%: A randomized, double-masked, placebo-controlled trial. J Refract Surg. 2002;18:140-144.

Perry HD, Donnenfeld ED, Acheampong A, Kanellopoulos AJ, Sforza PD, D’Aversa G, Wallerstein A. Stern M topical cyclosporine A in the management of postkeratoplasty glaucoma and corticosteroid-induced ocular hypertension (CIOH) and the penetration of topical 0.5% cyclosporine A into the cornea and anterior chamber. CLAO J. 1998;24(3):159-165.

Donnenfeld ED, Selkin BA, Perry HD, et al. Controlled evaluation of a bandage contact lens and a topical nonsteroidal anti-inflammatory drug in treating traumatic corneal abrasions. Ophthalmology. 1995;102(6):979-984.

Discussion

NSAIDs in cataract surgery

Donnenfeld: The patient expectations for cataract surgery in 2005 include no pain, no complications, white, quiet eyes and rapid visual rehabilitation. Nonsteroidals allow ophthalmologists to achieve these patient expectations in many different ways.

Dr. Katsev, how do NSAIDs improve outcomes in cataract surgery?

Douglas Katsev, MD: NSAIDs reduce the incidence of postoperative CME. Intraoperatively, the most important issues that I encounter are maintaining pupil dilation for capsulorrhexis and patient comfort. NSAIDs are crucial for both of these functions.

Donnenfeld: I agree. I find one of the most challenging situations that I encounter during surgery is blepharospasm, or uncontrolled blinking. Using a lid speculum and an NSAID in conjunction with topical anesthetic dramatically reduces this phenomenon, making surgery easier for the surgeon and the patient.

NSAIDs vs. corticosteroids

Donnenfeld: What is the role of corticosteroids and what are the complications associated with their use after cataract and refractive surgery?

Chang: With cataract surgery, the more rapidly surgeons can eliminate inflammation and restore the blood-aqueous barrier, the better. In this regard, the benefits of corticosteroids and NSAIDs are additive because they work at different points along the arachidonic acid synthesis pathway. NSAIDs are more efficacious in preventing CME, while steroids are better at eliminating the inflammatory cells. I will use NSAIDs alone in steroid responders, advanced glaucoma patients and patients with prior ocular herpetic infections. However, the problem with routinely eliminating topical steroids postoperatively is that some eyes still exhibit prolonged iritis.

Perry: Wound healing can become critical in certain patients, and wound healing is significantly inhibited by corticosteroids. There is also the potentiation in terms of viral infections and corticosteroid-induced ocular hypertension. Five percent of patients on topical corticosteroids will have an increase in IOP between 5 mm Hg and 20 mm Hg. In glaucoma patients, 92% will have a hypertensive response to topical corticosteroids.

Donnenfeld: Corticosteroids are immunosuppressives whereas nonsteroidals are immunomodulators. One advantage of NSAIDs is that they can be stopped without any inflammatory sequelae, while corticosteroids must be tapered to avoid inflammatory rebound.

Pain management

Donnenfeld: How do you use NSAIDs to control pain in cataract and refractive surgery?

Katsev: In my LASIK practice, I give patients preservative-free ketorolac tromethamine 0.4% postoperatively and perform operations in the evening so patients can go home and go to sleep. Ketorolac helps control pain and counteracts the scratchy, burning feeling.

Terry Kim, MD: I use preservative-free ketorolac tromethamine 0.4% immediately before and after surface ablation surgery and then recommend its use as necessary until the point of epithelial healing. This regimen helps with postoperative pain and may also help with inflammation.

For cataract surgery, I dose ketorolac tromethamine 0.4% the day before surgery and in the preoperative holding area, along with dilating drops the day of surgery. This helps to maintain good analgesia and prevent intraoperative pupil constriction.

Postoperatively, I dose ketorolac tromethamine 0.4% four times a day for 4 weeks for routine cases, which addresses the problem of postoperative pain that a corticosteroid does not.

Donnenfeld: When you use topical nonsteroidals, what percentage of patients require additional medication stronger than over-the-counter oral NSAIDs?

Kim: In my surface ablation procedures, I have found that less than 10% of patients require stronger oral painkillers. Topical NSAIDs keep patients from having to go to stronger oral medications, whether prescription or nonprescription, and do not generate the unwanted side effects of oral narcotics.

Donnenfeld: In our practice, we find it helpful to pre-soak a bandage contact lens in NSAIDs. It acts as a depot to improve pain control.

Perry: If we can help break the cycle of blepharospasm — the patient leaving anesthetized but having a painful reaction later and experiencing subsequent blepharospasm — I think we will have less striae. Using an NSAID in the first postoperative 24 hours is helpful in breaking that cycle.

Donnenfeld: The use of NSAIDs dramatically blunts the increase in pain that occurs when an anesthetic wears off. Dr. Perry and colleagues and I have conducted studies that have shown that NSAIDs provide a gradual, slow curve of pain return, over 1 to 2 hours.²

Bromfenac seems to have a longer duration of action than other NSAIDs, which may be beneficial after refractive surgery, where you want the patient to be comfortable for 2 to 4 hours until re-epithelialization allows the clot to stay in place.

Chang: The analgesic effect of NSAIDs in cataract surgery is advantageous, but without the prophylactic CME benefits, I would not prescribe them solely for this reason. In addition, ketorolac and diclofenac both sting, which is a comfort tradeoff.^3,4 According to the Japanese literature, there is a lower incidence of stinging and burning with bromfenac than with ketorolac.⁵

Donnenfeld: In my clinical experience, flurbiprofen is significantly weaker than the other medications in pain control. It provides less control of pain, less pupillary mydriasis and it has no significant effect on CME.