Variety of remedies available for postoperative challenges

Experts discuss ways to control complications after the implantation of a refractive multifocal IOL and pain after PRK.

Eric D. Donnenfeld, MD: Refractive IOLs are basically high-wire acts where everything has to be perfect, and you do not want to have a patient who has complications because your margin of error is much smaller.

Eric D. Donnenfeld

In this case, a 55-year-old hyperopic woman is a perfect surgery candidate with no epiretinal membrane. But she complains of significant glare and halos after surgery. She is using prednisolone acetate four times a day.

What are the treatable causes of glare, halo and loss of contrast after implantation of multifocal IOLs? Some of the causes include minimal refractive error, posterior capsular opacities, ocular surface disease and cystoid macular edema (CME). You examine this patient and find that optical coherence tomography reveals a little bit of foveal thickening. How do you treat this patient who has come in to your office for a second opinion? Dr. Bucci, what would you do?

Frank A. Bucci, MD: I would add a nonsteroidal four times a day.

Dr. Donnenfeld: And how long would you keep a patient on nonsteroidals?

Frank A. Bucci Jr.

Dr. Bucci: It could be relatively extended because you would follow her symptoms, follow the OCT and follow her visual acuity. It could be months before you taper it down to twice a day. But basically, we would be looking at the vision, the symptoms and the OCT.

Dr. Donnenfeld: What is a natural course for a patient who has mild CME with a multifocal IOL? What happens to them down the line after the CME is resolved? Do you think they get back the same visual acuity as if they never had CME?

Dr. Bucci: You can get epiretinal membranes much more frequently. And the idea would be to treat her early enough that you could resolve it completely. But if you looked at a large number of patients, you would have some subtle loss of quality of vision. You are already losing some contrast to start with, so this is what we want to avoid.

Kerry D. Solomon

Terrence P. O’Brien, MD: I think prevention is far better than treatment in these cases because it is just like if your carpet gets flooded. Even though it dries out, it is never the same. And I think you are far better to prevent the CME than to try to treat it after the fact.

Kerry D. Solomon, MD: I also think it is reasonable to be a little more aggressive. In this patient, I think putting them on an NSAID four times a day is an absolute must. But I would follow them closely. If there is not much of an effect within 4 weeks or if they have dramatic amounts of macular thickening, I would send them to a retina specialist and let them get an intravitreal injection of a steroid.

Terrence P. O'Brien

Dr. Donnenfeld: Is there any role for oral prednisone in these patients?

Calvin W. Roberts, MD: There may be a role for oral Diamox (acetazolamide). I am pretty liberal about giving out Diamox, assuming that their health is otherwise good. Diamox Sequels 500 mg twice a day for 2 weeks often does a world of good in terms of thinning down the macula.

Reducing pain after PRK

Dr. Donnenfeld: With the advent of these multifocal IOLs, we are going to see more comprehensive ophthalmologists moving to doing corneal refractive surgery from dealing with the enhancements. If you are moving to do refractive surgery, I think the first place to start is with surface ablation. It is easier to learn, and there is less downside risk. So I think it is good to have an understanding of how to deal with the most common complication of surface ablation, which is pain. Dr. Trattler, you have done a lot of work on pain in PRK. Tell us how you prevent or reduce the incidence of pain with PRK.

Calvin W. Roberts

William B. Trattler, MD: Our pain control is so much better than it was in the past. There are so many different options to help control pain. Intraoperatively, you can chill the cornea with either a Merocel frozen sponge or ice cold balanced salt solution right after the ablation. It releases heat and helps reduce pain. As for topical medications, either dilute or full strength tetracaine drops can be used postoperatively to help control pain. And, of course, routine use of topical nonsteroidals is a big plus as well. They have been shown to reduce pain and make patients more comfortable.

As far as lens choice, the Acuvue Oasys (Vistakon) in my hands and in many people’s hands is a next-generation contact lens that also has helped reduce pain.

The other thing that has been helpful is to identify patients who have preoperative dry eye. If patients have dry eye before surgery, they are more likely to have an irritated ocular surface postoperatively, which will result in more pain after surgery. So it is important to identify dry eye patients ahead of time. I place punctal plugs to raise the tear film and use topical cyclosporine to help improve tear film quality. These steps can all make a big impact on patient comfort.

Dr. Donnenfeld: Do you treat your patients with NSAIDs before PRK, treat at time of surgery or treat afterward? Where do you apply the NSAIDs?

Terry Kim

Dr. Trattler: When I was using oral NSAIDs, which I am not doing now, I was starting them 1 day ahead of time. There are some doctors who start topical NSAIDs 1 day before surgery. It may make sense, but it is not my current practice.

Dr. Donnenfeld: Does anyone have any significant differences or comments they want to add? Does everyone use NSAIDs with PRK? And how long do you use them postoperatively?

Terry Kim, MD: I typically start topical NSAIDs immediately after the surface ablation procedure and continue them for 3 days. Usually by then, the epithelial defect has healed in the majority of patients, so I generally discontinue their bandage contact lens as well as the topical NSAID at this time. After the ablation, I apply chilled balanced salt solution and balanced salt solution popsicle sticks to the cornea. I then apply the topical NSAID directly on the cornea after the placement of the bandage contact lens. I have had the opportunity to use the newer-generation NSAIDs, including nepafenac and bromfenac, in this setting and have not encountered any differences in epithelial healing rates.

William B. Trattler

Dr. Donnenfeld: I do not think there is any real role for using NSAIDs for more than 3 days after PRK because at that point, if it has not healed, you want to promote healing more than anything else. So I think 3 days is kind of the limit for me for using NSAIDs after PRK. Does anyone do differently?

Dr. Bucci: I have found that the pain my PRK patients are experiencing now is substantially decreased vs. the past. I use an NSAID immediately after surgery, then make it available to the patient on an as-needed basis. I tell them, “If you have severe pain or discomfort, go ahead and use the NSAID. If you can do without it, I would rather have the epithelium heal quicker.” Most of my patients come back and say that they have had little pain beyond the first night of surgery.

A few years back, I performed a study comparing immediate postop to four times a day for 1 day and four times a day for 3 days using NSAIDs post-PRK. The results indicated that using NSAIDs past the first day postop actually provided diminishing margin returns. The patients did better with Refresh Tears (Allergan) as a control. NSAIDs for the first 24 hours only was the most effective.

Oral pain control

Dr. Donnenfeld: I am always interested in what ophthalmologists use for oral pain control. Tell us what oral medication you give for pain in patients after PRK.

Francis S. Mah

Francis S. Mah, MD: I start with 600 mg to 800 mg of ibuprofen before the procedure on the day of surgery. Afterward, I tell patients that they can take at least for 1 day the 800 mg or the 600 mg. Probably 90% of the patients do great with that, and they do not need anything stronger. Otherwise, we will give them, for example, Percocet (oxycodone and acetaminophen). But usually it is the ibuprofen.

Dr. O’Brien: We start with Percocet right off the bat on an as-needed basis in addition to the NSAID.

Dr. Bucci: Yes, the same thing for me.

Dr. Roberts: And for me.

Dr. Trattler: I use Celebrex (cele coxib) if needed.

Dr. Kim: I use ibuprofen.

Dr. Solomon: I do not use any.

For more information:

• Frank A. Bucci, MD, can be reached at Bucci Laser Vision Institute, 158 Wilkes-Barre Township Blvd., Wilkes-Barre, PA 18702; 570-825-5949; fax: 570-825-2645; e-mail: buccivision@aol.com.
• Eric D. Donnenfeld, MD, can be reached at Ophthalmic Consultants of Long Island, 2000 North Village Ave., Rockville Centre, NY 11570; 516-766-2519; fax: 516-766-3714; e-mail: eddoph@aol.com.
• Terry Kim, MD, can be reached at Duke University Eye Center, 2351 Erwin Road P.O. Box 3802, Durham, NC 27710-3802; 919-681-3568; fax: 919-681-7661; e-mail: terry.kim@duke.edu.
• Francis S. Mah, MD, can be reached at University of Pittsburgh Medical Center, Eye and Ear Institute, 203 Lothrop St., 8th Floor, Pittsburgh, PA 15213; 412-647-2200; fax: 412-647-5119; e-mail: mahfs@upmc.edu.
• Terrence P. O’Brien, MD, can be reached at Bascom Palmer Eye Institute, 7108 Fairway Drive, Palm Beach Gardens, FL 33418; 561-515-1544; fax: 561-515-1588; e-mail: tobrien@med.miami.edu.
• Calvin W. Roberts, MD, can be reached at 876 Park Ave., New York, NY 10021; 212-734-7788; fax: 212-734-4476; e-mail: robertsmd1@aol.com.
• Kerry D. Solomon, MD, can be reached at Medical University of South Carolina, Storm Eye Institute, 167 Ashley Ave., Room 221, PO Box 250676, Charleston, SC 29425; 843-792-8854; fax: 843-792-6347; e-mail: solomonk@musc.edu.
• William B. Trattler, MD, can be reached at 8940 N. Kendall Drive, #400, Miami, FL 33176; 305-598-2020; fax: 305-274-0426; e-mail: wtrattler@gmail.com. Dr. Trattler consults, lectures or receives support from Allergan, Inspire, Advanced Medical Optics and Ista.