Pain Reduction After Photoablation
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Introduction
Refractive surgery was first approved by the FDA in 1995 to surgically correct refractive error, and now is routinely used in daily practice by ophthalmologists [1]. Laser in situ Keratomileusis (LASIK) is the most popular refractive surgery technique performed because of the quick recovery time and limited pain after the procedure. Not all patients that qualify for refractive surgery are good candidates for LASIK. Therefore, Photorefractive keratectomy (PRK) may be a better option for patients with epithelial basement membrane disease or inadequate corneal thickness [2]. The most prominent drawbacks to PRK are its longer recovery time and the increased risk for ocular pain after the procedure [2][1][3]. Multiple studies have been performed to address a way to control pain after refractive surgery. These studies looked at oral medication versus topical medication, bandage contact lenses, as well as the best time to begin a pain regimen. However, no definitive method has proved to be the most reliable for mitigating pain after surface ablation.
Pre-operative Considerations
Dry eye is the leading cause of pain and discomfort after refractive surgery. Artificial tears, nutritional supplements such as omega 3 fatty acids and flax seed oil, lacrimal punctal occlusion, lifitegrast and topical cyclosporine may alleviate the symptoms of dry eye. LASIK induces neurotrophic epitheliopathy and thus causes ocular dryness. Topical cyclosporine 0.05% improves the symptoms of dryness by treating underlying inflammation and enhances nerve regeneration [4]. Studies have looked at pre-treating PRK patients with GABA-analogs such as gabapentin and pregabalin. These studies have not shown any statistical significance in reducing post-operative pain [2]. Another controlled study showed a significant reduction of post-PRK ocular pain when pre-treating eyes with topical diclofenac, which is a non-steroidal anti-inflammatory drug (NSAID), two hours prior to surgery [3].
Post-Operative Considerations
Ocular pain is common during the early post-operative period after PRK. The American Academy of Ophthalmology published an Ophthalmic Technology Assessment in 2022 summarizing the evidence for various interventions to treat or reduce pain after PRK.[5] The authors concluded that systemic opiates, systemic NSAIDs, topical NSAIDs, topical anesthetics, cold compresses/patches, and bandage contact lenses reduced pain after PRK. A meta-analysis concluded that systemic NSAIDS and opioid medications, topical NSAIDS, cold patches, bandage contact lenses, and topical anesthetics provided improved pain control over other treatments.[6]
Systemic medications:
Systemic diclofenac and systemic opiates have both been found to reduce pain after PRK.[5] The evidence is mixed regarding systemic gabapentin and prebabalin. A prospective, randomized, controlled study evaluated three groups: one was given a placebo, one was given pregabalin 75mg orally, and was given gabapentin 300mg orally. This study did not find any significant difference in pain control [2]. Another study evaluated post-PRK pain control with gabapentin 300mg orally versus oxycodone and acetaminophen. In this study, the gabapentin group felt significantly less pain on the morning of the second post-operative day only [1].
Oral analgesics can be used as a “rescue medication” [2] if topical eye drops are not providing adequate analgesia for post-operative pain. It has been shown that patients who used both a post-operative oral NSAID and a bandage contact lens resorted to less consumption of prescribed oral analgesics [7].
Topical medications:
Topical NSAIDS
NSAIDs are used commonly after PRK due to its effectiveness at reducing pain and interference n the prostaglandin pathway following corneal trauma. [7] In general, topical NSAIDs have been found to reduce pain after PRK.[5] One study did not use any pain medications or eye drops before performing LASIK, but looked at the efficacy of one drop of topical diclofenac immediately after the procedure. The results showed patients who received diclofenac were less symptomatic four hours after the procedure [8]. Another study showed no significant differences in safety or discomfort with use of bromfenac 0.09% twice daily versus ketorolac 0.4% 4 times a day post-operatively.[9] With topical NSAIDs, there is associated risk of corneal toxicity and melting. By using a single dose approach after surgery, pain relief is provided with limited chance of corneal toxicity [8].
Topical cycloplegics
One study found that homatropine reduced pain after PRK, but this was not superior to topical diclofenac.[10] Topical cycloplegics are not routinely used after PRK.
Topical anesthetics
Another method of postoperative pain control is topical anesthetic, which is controversial, given the risk of delayed epithelial healing with topical anesthetic. However, older studies had concluded that dilute proparacaine 0.05% or giving patients 10 drops of non-dilute tetracaine 0.5% did not extend the number of days to epithelial healing compared to patients not receiving postoperative anesthetic drops[5][11]. This is controversial and not widely recommended.
Cryoanalgesia:
Chilled balanced salt solution used intraoperatively immediately after excimer laser treatment has not been shown to decrease postoperative pain, but is a common practice.[12] There is some suggestion that chilled saline may reduce the risk of haze formation, regardless of its impact on pain.[13] Application of cold patches on the eyelids every 30 minutes for 24 hours post-operatively, while the patient is awake, was found to significantly decrease pain.[14]
Bandage contact lenses:
After surface ablation procedures such as laser epithelial keratomileusis (LASEK ) or PRK, bandage contact lenses are routinely applied to patients’ eyes to help re-epithelialization and healing to improve comfort and reduce pain, [15] [16] and are considered the standard of care after PRK. All bandage contact lenses were found to reduce pain (both FDA-approved and off-label usage), although less pain was reported with senofilcon A (Acuvue Oasys, Johnson & Johnson).[5] In addition, bandage contact lenses can act as a reservoir for the medication such as NSAIDs for sustained release [17].
Conclusion
The post-operative risk of ocular pain after corneal photorefractive surgery should be discussed with all patients. Pre-operative and postoperative topical NSAID drops such as diclofenac, ketorolac, and bromfenac, oral gabapentin, bandage contact lenses, cold patches, and oral analgesics are tools available for pain management.
References
- ↑ 1.0 1.1 1.2 Nissman, Steven, Rochelle Tractenberg, Anita Babbar-Goel, and Joseph Pasternak. "Oral Gabapentin for the Treatment of Postoperative Pain after Photorefractive Keratectomy." American Journal of Ophthalmology 145 (2008): 623-29. Web.
- ↑ 2.0 2.1 2.2 2.3 2.4 Pakravan, Mohammad, Maryam Roshani, Shahin Yazdani, Amir Faramazi, and Mehdi Yaseri. "Pregabalin and Gabapentin for Post-photorefractive Keratectomy Pain: A Randomized Controlled Trial." European Journal of Ophthalmology 22.7 (2012): S106-113. Web.
- ↑ 3.0 3.1 Mohammadour, Mehrdad, MD, Mahmood Jabbarand, MD, Mojgan Nikdel, MD, Mohsen Adelpour, MD, and Nasser Karimi. "Effect of Preemptive Topical Diclofenac on Postoperative Pain Relief after Photorefractive Keratectomy." Journal of Cataract and Refractive Surgery 37 (2011): 633-37. Web.
- ↑ Nettune, GR, MD, and SC Plfugfelder, MD. "Post-LASIK Tear Dysfunction and Desesthesia." Ocular Surface 8.3 (2010): 135-45. Web. 18 Nov. 2012.
- ↑ 5.0 5.1 5.2 5.3 5.4 Shahinian et al. Dilute topical proparacaine for pain relief following photorefractive keratectomy. Ophthalmology 1997;104(8):1327-32.
- ↑ Steigleman WA, Rose-Nussbaumer J, Al-Mohtaseb Z, Santhiago MR, Lin CC, Pantanelli SM, Kim SJ, Schallhorn JM. Management of Pain after Photorefractive Keratectomy: A Report by the American Academy of Ophthalmology. Ophthalmology 2023;130(1):87-98.
- ↑ 7.0 7.1 Arshinoff, Steve A., MD, Michael D. Mills, BSc, and Susan Haber, BSc. "Pharmacotherapy of Photorefractive Keratectomy." Journal of Cataract and Refractive Surgery 22 (1996): 1037-043. Web.
- ↑ 8.0 8.1 Parker, Jared, MD, Amit Tandon, MD, Roni Shtein, MD, H. Kaz Soong, MD, Theresa N. Cooney, MD, David C. Musch, PhD, MPH, and Shahzad I. Mian, MD. "Management of Pain with Diclofenac after Femtosecond-assisted Laser in Situ Keratomileusis." Journal of Cataract and Refractive Surgery 37 (2011): 569-73. Web.
- ↑ Sher N, Golben M, Bond W, Trattler W, Tauber S, Voirin T. Topical bromfenac 0.09% vs ketorolac 0.4% for the control of pain, photophobia, and discomfort following PRK. J Refract Surg 2009;25(2):214-20.
- ↑ Abri Aghdam K, Aghaei H, Shokrollahi S, Joshaghani M, Nazari H, Hashemi M, Ghaempanah MJ. Comparison of the effect of cycloplegic versus NSAID eye drops on pain after photorefractive keratectomy. J Curr Ophthalmol. 2016 Jan 8;27(3-4):87-91. doi: 10.1016/j.joco.2015.11.006. PMID: 27239584; PMCID: PMC4881241.
- ↑ Brilakia and Deutsch. Topical tetracaine with soft bandage contact lens pain control after photorefractive keratectomy. J Refract Surg 2000;16(4):444-7.
- ↑ S. Zarei-Ghanavati, N. Nosrat, N. Morovatdar, et al. Efficacy of corneal cooling on postoperative pain management after photorefractive keratectomy: a contralateral eye randomized clinical trial. J Curr Ophthalmol 2017;29:264-269.
- ↑ Kitazawa Y, Tokoro T, Ito S, Ishii Y. The efficacy of cooling on excimer laser photorefractive keratectomy in the rabbit eye. Surv Ophthalmol. 1997 Nov;42 Suppl 1:S82-8. doi: 10.1016/s0039-6257(97)80030-6. PMID: 9603293.
- ↑ Zeng Y, Li Y, Gao JH. Application of cold patch in relieving pain after transepithelial photorefractive keratectomy. Pain Res Manag 2015;20:195-198.
- ↑ Gil-Cazorla R, Teus MA, Hernández-Verdejo JL, De Benito-Llopis L, García-González M. Comparative study of two silicone hydrogel contact lenses used as bandage contact lenses after LASEK. Optom Vis Sci 2008; 85(9):884-8.
- ↑ Szaflik JP, Ambroziak AM, Szaflik J. Therapeutic use of a lotrafilcon A silicone hydrogel soft contact lens as a bandage after LASEK surgery. Eye Contact Lens 2004; 30(1):59-62.
- ↑ Cherry, Paul M.H., FRCS. "The Treatment of Pain following Excimer Laser Photorefractive Keratectomy: Additive Effect of Local Anesthetic Drops, Topical Diclofenac, and Bandage Contact Lens." Ophthalmic Surgery and Lasers 27.5 (1996): S477-480. Web.
