Efficacy of Diclofenac in Pain Reduction after Topography-Guided Transepithelial Surface Ablation

Abstract

Purpose To report the efficacy of postoperative diclofenac eye drops for pain reduction in patients undergoing topography-guided transepithelial surface ablation.

Methods Retrospective consecutive case series of patients undergoing topography-guided transepithelial surface ablation for refractive myopia treatment using a 1 KHz excimer laser. Patients were divided into three groups. Group 1 did not receive any diclofenac drops, group 2 received one diclofenac drop postoperatively (day 1), and group 3 received one drop of diclofenac postoperatively (day 1) and on the day after treatment (day 2). Postoperative pain was self-assessed by patients per eye daily for the first 4 consecutive days (days 1 to 4) after the treatment using the visual analogue scale (VAS). We compared VAS with respect to the use of additional oral or topical treatment as well as VAS with regards to the total amount of ablated tissue (< 50 µm, 50 – 100 µm, ≥ 100 µm) among the groups.

Results We enrolled 163 eyes of 163 patients (55.0% female), with a mean age of 31.3 years (SD ± 6.6; range 21 – 68). We excluded 16 patients who applied other additional analgesics. Group 1 comprised 35 eyes (21%), group 2 had 21 eyes (13%), and group 3 consisted of 107 eyes (66%). Median pain score (VAS) was 5 (range 0, 10) in group 1, which was higher than in groups 2 (median 1, range 0 to 7) and 3 (median 1.5, range 0 to 7) on the day of surgery (p < 0.0001). Percentage of patients using an additional oral NSAID on days 1 and 2 was significantly higher in group 1 (69/83%) when compared to groups 2 (24/43%) or 3 (31/49%) (p < 0.001 day 1, p = 0.001 day 2). No correlation was found between pain sensation and maximum ablation depth (Spearman correlation p > 0.05).

Conclusion The instillation of one drop of diclofenac after topography-guided transepithelial surface ablation reduced subjective pain sensation according to VAS and decreased the need for additional topical anesthetic drops or oral NSAID.

Zusammenfassung

Studienziel Beurteilung der Effektivität der postoperativen Applikation von Diclofenac-Augentropfen zur Schmerzreduktion bei Patienten, die sich einer topografiegesteuerten transepithelialen Oberflächenablation unterziehen.

Methoden Retrospektive, konsekutive Fallserie von Patienten, die sich einer topografiegesteuerten transepithelialen Oberflächenablation zur refraktiven Behandlung einer Myopie mit einem 1-KHz-Excimer-Laser unterzogen. Die Patienten wurden in 3 Gruppen eingeteilt. Gruppe 1 erhielt keine Diclofenac-Tropfen, Gruppe 2 erhielt postoperativ (Tag 1) 1 Diclofenac-Tropfen und Gruppe 3 erhielt postoperativ (Tag 1) und am Tag nach der Behandlung (Tag 2) 1 Tropfen Diclofenac. Die postoperativen Schmerzen wurden von den Patienten in den ersten 4 Tagen nach der Behandlung (Tag 1 – 4) täglich pro Auge anhand der visuellen Analogskala (VAS) selbst eingeschätzt. Wir verglichen die VAS in Bezug auf die Verwendung einer zusätzlichen oralen oder topischen Behandlung sowie die VAS in Bezug auf die Gesamtmenge des abgetragenen Gewebes (< 50 µm, 50 – 100 µm, ≥ 100 µm) zwischen den Gruppen.

Ergebnisse Wir schlossen 163 Augen von 163 Patienten (55,0% weiblich) mit einem Durchschnittsalter von 31,3 Jahren (SD ± 6,6; Bereich 21 – 68) ein. Es wurden 16 Patienten, die zusätzlich andere Analgetika einnahmen, ausgeschlossen. Gruppe 1 umfasste 35 Augen (21%), Gruppe 2 21 Augen (13%) und Gruppe 3 107 Augen (66%). Der mediane Schmerzscore (VAS) betrug in Gruppe 1 5 (Spanne 0 – 10) und war damit höher als in Gruppe 2 (Median 1, Spanne 0 – 7) und Gruppe 3 (Median 1,5, Spanne 0 – 7) am Tag der Operation (p < 0,0001). Der Prozentsatz der Patienten, die am Tag 1 und 2 zusätzlich orale NSAR einnahmen, war in Gruppe 1 (69%/83%) signifikant höher als in Gruppe 2 (24%/43%) bzw. Gruppe 3 (31%/49%) (p < 0,001 Tag 1, p = 0,001 Tag 2). Es wurde keine Korrelation zwischen Schmerzempfindung und maximaler Ablationstiefe gefunden (Spearman-Korrelation p > 0,05).

Schlussfolgerung Die Applikation eines Tropfens Diclofenac nach der topografisch gesteuerten transepithelialen Oberflächenablation verringerte das subjektive Schmerzempfinden gemäß VAS und reduzierte den Bedarf an zusätzlichen topischen Anästhesietropfen oder oralen NSAR.

Key words

pain reduction - surface ablation - efficacy

Schlüsselwörter

Schmerzreduktion - transepitheliale Laserablation - Wirksamkeit

• References

• 1 Ang M, Gatinel D, Reinstein DZ. et al. Refractive surgery beyond 2020. Eye (Lond) 2021; 35: 362-382
• 2 Li SM, Kang MT, Wang NL. et al. Wavefront excimer laser refractive surgery for adults with refractive errors. Cochrane Database Syst Rev 2020; (12) CD012687
• 3 Seiler T, Huhle S, Spoerl E. et al. Manifest diabetes and keratoconus: a retrospective case-control study. Graefes Arch Clin Exp Ophthalmol 2000; 238: 822-825
• 4 Krueger RR, Mrochen M. Introduction to the proceedings of the Third International Congress of Corneal Cross-Linking. J Refract Surg 2008; 24: S713-S714
• 5 Golan O, Randleman JB. Pain management after photorefractive keratectomy. Curr Opin Ophthalmol 2018; 29: 306-312
• 6 Fagerholm P. Wound healing after photorefractive keratectomy. J Cataract Refract Surg 2000; 26: 432-447
• 7 Villani E, Baudouin C, Efron N. et al. In vivo confocal microscopy of the ocular surface: from bench to bedside. Curr Eye Res 2014; 39: 213-231
• 8 Erie JC, McLaren JW, Hodge DO. et al. Recovery of corneal subbasal nerve density after PRK and LASIK. Am J Ophthalmol 2005; 140: 1059-1064
• 9 Woreta FA, Gupta A, Hochstetler B. et al. Management of post-photorefractive keratectomy pain. Surv Ophthalmol 2013; 58: 529-535
• 10 Vetrugno M, Maino A, Quaranta GM. et al. The effect of early steroid treatment after PRK on clinical and refractive outcomes. Acta Ophthalmol Scand 2001; 79: 23-27
• 11 Vetrugno M, Maineo A, Quaranta GM. et al. A randomized, double-masked, clinical study of the efficacy of four nonsteroidal anti-inflammatory drugs in pain control after excimer laser photorefractive keratectomy. Clin Ther 2000; 22: 719-731
• 12 Vetrugno M, Maino A, Cardia L. Prospective randomized comparison of simultaneous and sequential bilateral photorefractive keratectomy for the correction of myopia. Ophthalmic Surg Lasers 2000; 31: 400-410
• 13 Shetty R, Dalal R, Nair AP. et al. Pain management after photorefractive keratectomy. J Cataract Refract Surg 2019; 45: 972-976
• 14 Stojanovic A, Chen S, Chen X. et al. One-step transepithelial topography-guided ablation in the treatment of myopic astigmatism. PLoS One 2013; 8: e66618
• 15 Razmju H, Khalilian A, Peyman A. et al. Preoperative Topical Diclofenac and Ketorolac in Prevention of Pain and Discomfort Following Photorefractive Keratectomy: A Randomized Double-masked Placebo-controlled Clinical Trial. Int J Prev Med 2012; 3: S199-S206
• 16 Hong JP, Nam SM, Im CY. et al. Comparison of analgesic effect of preoperative topical diclofenac and ketorolac on postoperative pain after photorefractive keratectomy. J Cataract Refract Surg 2014; 40: 1689-1696
• 17 Boynton PM, Greenhalgh T. Selecting, designing, and developing your questionnaire. BMJ 2004; 328: 1312-1315
• 18 Klimek L, Bergmann KC, Biedermann T. et al. Visual analogue scales (VAS): Measuring instruments for the documentation of symptoms and therapy monitoring in cases of allergic rhinitis in everyday health care: Position Paper of the German Society of Allergology (AeDA) and the German Society of Allergy and Clinical Immunology (DGAKI), ENT Section, in collaboration with the working group on Clinical Immunology, Allergology and Environmental Medicine of the German Society of Otorhinolaryngology, Head and Neck Surgery (DGHNOKHC). Allergo J Int 2017; 26: 16-24