Diclofenac sodium anti-inflammatory also effective pain reliever

Issue: January 1998

Voltaren (diclofenac sodium 0.1%, Ciba Vision Ophthalmics) was initially approved for treatment of postoperative inflammation following cataract surgery. Some surgeons switched to Voltaren as their drug of choice after cataract surgery, but most continued to use the time-proven anti-inflammatory prednisolone acetate 1%. Reports and studies began to conclude that Voltaren did help relieve pain after injury or anterior segment surgery, especially radial keratotomy (RK).

Diclofenac sodium 0.1% solution has now been approved for photophobia after incisional refractive surgery and for discomfort following laser refractive correction procedures. It seems that Voltaren is evolving into a very useful tool for managing anterior segment pain. Later in this article, I will discuss nonapproved uses in addition to the approved uses of Voltaren for postoperative cataract inflammation, RK and laser refractive procedures.

No benzalkonium chloride

Voltaren is a topical nonsteroidal anti-inflammatory eye drop (there is also an oral form) supplied in 2.5-mL and 5.0-mL bottles. It is preserved with boric acid, edetate disodium and sorbic acid. This is one of the few ophthalmic medications available that does not contain benzalkonium chloride. It is contraindicated for use when patients are wearing their soft contact lenses. Used sparingly with bandage lenses after injuries or refractive surgery, diclofenac sodium 0.1% is helpful in reducing pain.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are close cousins to aspirin; therefore, cross sensitivity is possible and should be a consideration when prescribing Voltaren. The Voltaren package insert cautions that prolonged bleeding may occur after surgery with patients having known bleeding tendencies or taking other blood thinners. Healing may be delayed as with all steroid or NSAID medications. However, studies monitoring healing with Voltaren and a placebo did not find a statistically significant difference in the healing response.

About 15% of the patients reported burning and stinging on instillation during the initial clinical trials. Effectiveness and safety have not been established for pediatric patients. However, using Voltaren for short periods to help relieve pain from corneal abrasions would seem to be a logical and a safer approach than prescribing oral analgesics for a child.

Off-label uses

I asked Waymon Harrison, OD, center director for TLC The Laser Center in Oklahoma City about his thoughts on Voltaren. "As you know, Voltaren has been approved for usage after cataract surgery and incisional refractive surgery," he said, "but it has also been used off-label to help control pain after photorefractive keratectomy (PRK) and laser in situ keratomileusis (LASIK). (It is now approved for pain after laser correction.) At TLC we use one drop of Voltaren preop and postop in both PRK and LASIK patients. We also prescribe Voltaren twice daily for the first 2 days post-PRK to help with the irritation."

Dr. Harrison does not use Voltaren in patients with known hypersensitivity, and he recommends monitoring patients who are on other blood thinners because it may prolong bleeding.

"As for side effects, it has been noted by many observers that prolonged usage post-PRK may lead to sterile infiltrates that can cloud the clinical picture as to whether infectious keratitis might be starting. At TLC we observed this infiltrate more when we used diclofenac sodium four times daily while the cornea re-epithelialized. Due to this clinical observation, we reduced the dosage to twice daily for 2 days after the procedure," he added.

"I have also found that Voltaren is useful in treating postoperative cataract cystoid macular edema in combination with Pred Forte (prednisolone acetate, Allergan)," Dr. Harrison continued. Dosage is diclofenac sodium four times daily and Pred Forte four times daily for 4 to 6 weeks and then the dosage is tapered slowly.

Treatment plans

The accompanying charts outline approved treatment plans for various conditions. The following are nonapproved uses of Voltaren:

To relieve pain with anterior limiting membrane disease, use one drop four times daily for 4 to 7 days, then taper to twice daily or at bedtime for a maintenance dose as needed.
To relieve discomfort and inflammation with epidemic keratoconjunctivitis, use one drop four times daily for 4 to 7 days during the acute phase of the infection. Another option would be to alternate Maxitrol (dexamethasone, Alcon) and Voltaren, using each drop twice daily.
For cystoid macular edema after cataract surgery, administer one drop four times daily for 4 to 6 weeks in combination with Pred Forte four times daily, and taper slowly after the initial treatment period.

More uses being discovered

Voltaren reminds me of aspirin. It has some side effects, but we keep finding more and more conditions that it seems to help. A careful history is important to discover any past problems with aspirin or other NSAIDs, and you need to know if the patient is taking other blood thinners. Infiltrates have been noted after PRK when using Voltaren and a bandage contact lens to reduce discomfort. These problems have generally been eliminated by reducing the dosage after the procedure.

Recent studies have looked at the potential of Voltaren for treating acute seasonal allergic conjunctivitis. The results were promising: less inflammation and improved comfort. As with aspirin, new, promising ways to use Voltaren to help solve some of our everyday clinical problems keep being discovered.

Patients with abrasions, welding burns, foreign bodies and chemical irritations really like Voltaren. Many times, these patients are able to go to work or at least gain enough relief to not have to resort to strong oral analgesics or narcotic pain relievers to make it through the recovery period. We can now more easily treat the site of the pain rather than prescribe oral pain relievers, which have more possibilities for physical side effects.

The anti-inflammatory properties should not be forgotten. An anti-inflammatory reduces the risk of scarring and secondary anterior uveitis. Pain relief, less risk of scarring, reduced risk of anterior uveitis, treatment at the site and few side effects add up to a lot of potential in one medication.

Prescribing Voltaren for Pain and Inflammation

After cataract surgery:

One drop four times daily for 1 to 3 weeks, as indicated by the surgeon. Wound healing and the anterior chamber reaction would dictate to the doctor how long each patient should continue the drop.

After RK:

One drop 1 hour prior to surgery, one drop within 15 minutes after surgery, then four times daily for up to 3 days as needed.

After PRK:

One drop 30 to 60 minutes before PRK, one drop within 30 minutes after PRK, then twice daily for 2 days.

After LASIK:

One drop 30 to 60 minutes before LASIK, then one drop within 30 minutes following LASIK.

After foreign body removal and for treating welding burns, abrasions, recurrent erosions and chemical keratitis:

One drop four times daily for 2 to 3 days. An antibiotic, such as Polytrim (trimethoprim sulfate, polymyxin B sulfate, Allergan), and oral pain relievers may also be needed.

For Your Information:

Voltaren is available from Ciba Vision Ophthalmics, 11460 Johns Creek Parkway, Duluth, GA 30097-1556.

Bobby Christensen, OD, FAAO, is in private practice and lectures widely on therapeutic pharmaceutical agents. He can be reached at Heritage Park Medical Center, 6912 E. Reno, Suite 101, Midwest City, OK 73110; (405) 732-2277; fax : (405) 737-4776. Dr. Christensen has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any company mentioned.