Are topical NSAIDs a safe and effective treatment

Are topical NSAIDs a safe and effective treatment for Corneal Abrasions? Department of Emergency Medicine University of Pennsylvania Health System Andrew Sheep, MD PGY-3 January 15 th, 2014

References • Congdon NG et al. Corneal complications associated with topical ophthalmic use of nonsteroidal anti-inflammatory drugs. J Cataract Refract Surg 2001; 27(4): 622– 631. • Szucs PA et al. Safety and efficacy of diclofenac ophthalmic solution in the treatment of corneal abrasions. Ann Emerg Med. 2000 Feb; 35(2): 131 -7. • Weaver CS, Terrell KM. Evidence-based emergency medicine. Update: do ophthalmic nonsteroidal anti-inflammatory drugs reduce the pain associated with simple corneal abrasion without delaying healing? Ann Emerg Med. 2003; 41: 134 -40 • Calder LA et al. Topical nonsteroidal anti-inflammatory drugs for corneal abrasions: meta-analysis of randomized trials. Acad Emerg Med. 2005 May; 12(5): 467 -73.

Congdon NG 2001 • Case reports from 1994 -2000 of complications of topical NSAIDs in corneal abrasion reported to the American Society of Cataract and Refractive Surgery • Cases were classified as "mild, " "moderate, " or "severe" according to predetermined clinical criteria. • 51 cases (36. 4%) were mild, 55 (39. 3%) moderate, and 34 (24. 3%) severe

Congdon NG 2001 • A mild case was defined as a condition limited to the corneal epithelium (persistent epithelial irritation) • A moderate case was characterized by loss or inflammation of corneal stromal substance (eg, stromal infiltration, ulceration, suppuration, or thinning) • A severe case had at least 1 of the following—wound leak, corneal perforation, use of tissue adhesive, or enucleation.

Congdon NG 2001 • Conclusion – Almost all cases of moderate and all cases of severe complications were in patients with comorbid DM, preexisting ocular pathology, or prolonged (>48 hours) use. • Limitations: – This is a series of case reports – Many of these patients had ocular surgery – Many patients used it >48 hours

Szucs PA 2000 • Szucs PA et al. Safety and efficacy of diclofenac ophthalmic solution in the treatment of corneal abrasions. Ann Emerg Med. 2000 Feb; 35(2): 131 -7.

Szucs PA 2000 • Prospective, randomized, double-blinded, placebocontrolled clinical trial of consecutive patients to a community ED, receiving either topical NSAID or placebo for corneal abrasion • 25 received diclofenac and 24 received placebo drops. Both groups were similar in gender, age, pretreatment pain duration, Numeric Pain Intensity Scale (NPIS) , and analgesic use.

Szucs PA 2000 • There was significantly greater improvement in the 2 -hour mean NPIS score in the diclofenac group 3. 1 (95% CI 2. 3 to 4. 0; Figure 1) compared with the control group 1. 0 (95% CI 0. 1 to 2. 0; P=. 002; Figure 2).

Szucs PA 2000

Szucs PA 2000 • Patients in the diclofenac group were half as likely to take oxycodone-acetaminophen rescue medication (20% of diclofenac patients [95% CI 4% to 36%] versus 42% of control vehicle patients [95% CI 22% to 62%]), although this was not statistically significant.

Szucs PA 2000 • No reported complications associated with shortterm diclofenac or placebo use. • No patients (0/49) followed for up 10 days developed a corneal infection during the study, and all reported complete resolution of pain and return to baseline visual acuity within 1 week of treatment.

Weaver CS 2003 • Weaver CS, Terrell KM. Evidence-based emergency medicine. Update: do ophthalmic nonsteroidal anti-inflammatory drugs reduce the pain associated with simple corneal abrasion without delaying healing? Ann Emerg Med. 2003; 41: 134 -40

Weaver CS 2003 • Meta-analysis was a search for randomized controlled trials from 1966 to 2002 assessing whether or not topical NSAIDs reduce the pain from corneal abrasions. • Total of 5 blinded, randomized, placebocontrolled trials involving NSAIDs for corneal abrasions

Weaver CS 2003 • The qualitative summary indicates that NSAIDs provide greater pain relief and improvement of other subjective symptoms when compared with placebo • The use of ophthalmic NSAIDs may decrease the need for sedating analgesics. • However, they’re more expensive than orals

Weaver CS 2003 • In clinical practice, the evidence gained from clinical trials must be placed in the context of clinician experience. • Patients who can afford the medication, must return to work immediately, and for whom potential opioid-induced sedation is intolerable are the most likely candidates for the administration of ophthalmic NSAIDs during the first 24 hours after a traumatic corneal abrasion.

Calder LA 2005 • Calder LA et al. Topical nonsteroidal antiinflammatory drugs for corneal abrasions: meta-analysis of randomized trials. Acad Emerg Med. 2005 May; 12(5): 467 -73.

Calder LA 2005 • This was a systematic literature review and metaanalysis of randomized clinical trials. • Outcomes were pain scale scores at 24 hours and adverse effects. • 11 RCTs met inclusion criteria. • Seven trials enrolled fewer than 100 patients, and more than half of the studies were conducted in Europe. Five trials reported suitable data for analysis.

Calder LA 2005 • Results – The overall weighted mean difference for 459 patients was a reduction in pain by 1. 30 points (95% confidence interval = -1. 56 to -1. 03) on the pain scale – Transient stinging was a commonly noted adverse effect. • Conclusions – Topical NSAIDs are effective analgesics for traumatic corneal abrasions.

HUPism • Topical NSAIDs such as diclofenac and ketorolac are safe and effective in uncomplicated corneal abrasion for acute and short-term pain relief, and can be considered as sole analgesic. • They should not be used in patients with preexisting ocular pathology. • They should not be used greater than 24 -48 hours.

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