Consider Exparel for postoperative eye pain
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Postoperative pain is the No. 1 complaint among our surgical patients, especially among those undergoing corneal cross-linking, which involves the creation of a 9-mm corneal epithelial defect.
For our cross-linking patients in particular, this pain is not only extremely unpleasant, but it is also highly discouraging. Many youngsters with keratoconus are so put off by the experience in their first eye that they refuse to have their second eye treated and, as a result, experience needless irreversible progression of their disease with permanent vision loss.
Cross-linking is not the only painful surgery that we do. Most of our surgeries involve, of course, sticking the eye with a knife. For any operation more involved than simple, straightforward cataract surgery (for instance, most corneal transplant surgeries), this means that most patients can expect to feel at least moderate discomfort for at least 24 hours after surgery. The day after surgery, we usually expect to hear comments about difficulty sleeping, waking up in the middle of the night or foreign body sensations. This is probably the norm at most practices.
Conventional oral analgesics have some utility here, and we tell patients to take over-the-counter pain relievers. However, for some procedures, such as cross-linking, even prescription opioid pain relievers are not completely satisfactory. One effective solution is sub-Tenon injection/block using lidocaine or bupivacaine, and that is the anesthesia we use intraoperatively to perform most of our complicated surgeries. However, the duration of action for these medications is often only a few hours, so while these injections do enable and facilitate the actual surgery, they do not solve the problem of post-procedural pain. However, recently, we have discovered something that makes a major difference.
Exparel (bupivacaine liposome injectable suspension, Pacira) is not a new medication. It has been around for more than a decade in the United States, used predominantly by orthopedic surgeons during joint work. It is a form of slow-release bupivacaine with a duration of action of 72 hours. Years ago, it was described as a retrobulbar block for long-term pain control in patients undergoing enucleation or evisceration, but otherwise, there is not much in the literature about its ophthalmic use. We learned about it when one of the anesthesiologists at the hospital where we operate suggested trying it for a patient having a repeat penetrating keratoplasty for an uncontrolled fungal ulcer. The next day and several days after, she was shockingly comfortable — in fact, completely comfortable for the first time in months.
After that experience, we began slowly using Exparel more, first in our complicated cases and then in the more routine. Over the past year, it has become our go-to surgical anesthetic for patients undergoing corneal transplants, lens exchanges and other bigger operations. The medication is delivered through sub-Tenon injection using a 5-cc syringe and a 19-gauge cannula. This method has recently been proven most effective in a specific administration. The first dose (1 cc) is given before the case begins, and the second dose (1 cc) is given at the completion of the case. While looking for the best way to minimize our patients’ complaints of discomfort, we discovered that a catheter, when inserted into the back of the eye, is able to give multiple safe injections with even less pain. The topical anesthetic eliminates pain from the surface; however, it does not provide better pain control during the surgeries or during the procedure when compared with Exparel.
Even more importantly, we have started using it in the clinic for our patients undergoing cross-linking. Aside from abandoning the postoperative posturing requirement for our Descemet’s membrane endothelial keratoplasties, switching to Exparel has done more to improve the postoperative comfort for our patients than any other thing that we have ever done. People are so much happier, especially the cross-linking patients, and much more eager to have their other eye operated on.
In the hospital, Exparel is a pass-through cost, and patients are charged nothing. In the clinic, the patient’s cost is about $300 per eye. This amount is not insignificant but well worth it.
Currently, we are enrolling a randomized study of patients treated with cross-linking with and without Exparel. In the meantime, we have been using the medication dozens of times a month for more than a year now, with far fewer complaints about post-procedural discomfort.
- Reference:
- Ang MJ, et al. Ophthalmic Plast Reconstr Surg. 2018;doi:10.1097/IOP.0000000000001218.
- For more information:
- Macy Green, of Parker Cornea in Vestavia Hills, Alabama, can be reached at macy.parkercornea@gmail.com.
- Daniel Norred, of the University of Alabama at Birmingham, can be reached at djnorred@uab.edu.
- Jack S. Parker, MD, PhD, of Parker Cornea in Vestavia Hills, Alabama, can be reached at jack.parker@gmail.com.
- Brooke Stansel of Parker Cornea in Vestavia Hills, Alabama, can be reached brookestansel@yahoo.com.
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