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BLOG: Why not NSAIDs for intractable dry eye/ocular surface disease-related pain?

ByDarrell E. White, MD

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I’ve been thinking a bit about my most challenging dry eye syndrome patients — those unfortunate few who are still uncomfortable even if they are dramatically better than they were at the onset of our mutual journey. Some of them, it turns out, have a really rare underlying problem, even rarer than superior limbic keratoconjunctivitis or molluscum contagiosum.

I usually figure these folks out eventually, given enough time. As in all of our practices, there’s an occasional diagnosis that’s so rarely seen in my type of practice setting that it only gets uncovered when I finally convince my patient that a second opinion is what she needs. Ocular pemphigoid was a recent example.

It’s usually not nearly that exotic, though. More often is the case that a relatively well-controlled case of dry eye syndrome or dysfunctional tear syndrome goes off the rails for a bit, for whatever reason. Increasing artificial tear use or jacking up the steroids doesn’t work. What to do then? There’s really nothing that’s approved for this, nor is there anything we typically turn to in this situation.

While ruminating on this, I came across a patient with chronic post-cataract pain (someone else’s post-op, thankfully) controlled with a topical NSAID. Eureka! Why not a topical NSAID for intractable dry eye syndrome/ocular surface disease pain? Anybody else remember that Acular (ketorolac tromethamine ophthalmic solution 0.5%, Allergan) was originally approved for itching associated with ocular allergy a classic ocular surface disease indication?

I’ll be starting to use this immediately. I will be using branded formulations only so that I don’t need to deal with the burning and stinging associated with almost all of the generic versions of these drugs in patients already in pain, not to mention the inevitable keratitis we see with the least expensive among them. Call it a “rescue drug” for intractable discomfort.

I’ll let you know what I find.