Sher and colleagues1 first described the use of topical diclofenac sodium after excimer laser photorefractive keratectomy in 1992. Since then, a number of studies have reported similar findings, the majority of which report the use of diclofenac sodium in combination with a bandage contact lens.24 Little has been reported about the use of topical diclofenac sodium in phototherapeutic keratectomy. We report a retrospective, matched control study of the analgesic and epithelial wound healing effects of diclofenac sodium in patients who underwent excimer laser phototherapeutic keratectomy with postoperative eye patching.
PATIENTS AND METHODS
One hundred thirty-four patients had excimer laser phototherapeutic keratectomy and were enrolled in the study. In 65 patients (65 eyes), topical diclofenac sodium (Voltaren Ophtha Sine, Ciba Vision, Wessling, Germany) was given before and after surgery three times a day for 3 to 4 days. The 69 control patients (69 eyes) had phototherapeutic keratectomy before topical diclofenac sodium was approved for ophthalmic use with laser surgery in Germany. The control patients remained medicated and hospitalized with binocular eye patching until they were pain-free or completely reepithelialized. The operative report and inpatient medical record were analyzed to assess epithelial wound healing and use of systemic analgesics.
Fifty-eight females and 76 males were included in this retrospective analysis. Sixty-four patients (47%) had recurrent erosions (32 eyes in the diclofenac group and 32 eyes in the control group; mean age of 43 years). In 50 patients (50 eyes; 37%), phototherapeutic keratectomy was used to smooth the corneal surface after pterygium surgery (23 eyes in the diclofenac group and 27 in control group; mean age of 52 years). Ten patients (10 eyes; 7.8%) suffered from band-like keratopathy (five eyes in the dicofenac group and five eyes in the control group; mean age of 68 years), and in 10 patients (10 eyes), phototherapeutic keratectomy was performed because of special indications such as corneal scars after infections and trauma or superficial corneal dystrophies (five eyes in the diclofenac group; five eyes in the control group; mean age of 42 years). There was no statistically significant difference in age and indication between the diclofenac and control groups.
Systemic Analgesic Use by Patients in Different Treatment Groups
Surgical Procedure and Medications
We used the Schwind Keratom 193nm excimer laser system (Schwind Co, Kleinostheim, Germany).5 Patients in the diclofenac group received topical diclofenac sodium (Voltaren Ophtha Sine) 15 minutes before, immediately after surgery, and every 8 hours after surgery for up to 4 days. All patients received oral paracetamol or suppositories of paracetamol and topical proxymetaeain 30 minutes before surgery, the latter as three doses separated by 10 minutes each. Ofloxacin eye ointment was administered immediately following the ablation. Patients received a bilateral eye patch and 500mg paracetamol for the first 1 to 2 days after surgery. Patients were permitted to order additional systemic analgesics (up to the allowed maximum dosage) according to their pain sensation, usually starting with paracetamol for little pain. If pain persisted, tramadol, metamizol, pethidin, or tihdin were used.
Seventy-two hours after phototherapeutic keratectomy, we found no statistical difference in the diameter of epithelial closure between the diclofenac and control groups. There were no systemic or local complications or allergic reactions.
Sixty-seven of 69 patients (approximately 95%) in the control group needed additional analgesics compared to 28 of 65 patients (approximately 43%) in the diclofenac sodium group. In patients with recurrent erosions, 33 of 33 patients (100%) in the control group compared to 15 of 32 patients (about 50%) in the diclofenac group needed additional systemic analgesics. In patients who had pterygium surgery, 27 patients (100%) in the control group compared to 10 of 23 patients (43%) in the diclofenac group needed additional systemic analgesics. In those with special indications, five patients (100%) in the control group ordered additional systemic analgesics and none of the five patients in the diclofenac group ordered additional systemic analgesics. In those with band-like keratopathy, two of five patients (40%) in the control group and one of five patients (20%) in the diclofenac group ordered systemic analgesics (Table).
Due to reasons of possible infectious and noninfectious (sterile) keratitis as well as effects on epithelial healing, contact lenses are not generally used after excimer laser phototherapeutic keratectomy in our hospital, but rather eye patching. Bilateral eye patching was used because it was thought to minimize eye movements leading to an improvement in epithelial wound healing beneath the patch. Both excimer laser photorefractive keratectomy and phototherapeutic keratectomy are associated with significant postoperative pain when topical nonsteroidal agents and contact lenses are not used. Diclofenac sodium reduces the need for systemic analgesics after excimer laser phototherapeutic keratectomy without coincident use of bandage contact lenses. We found no difference in epithelial wound healing after 3 days or incidence of sterile infiltrates when using diclofenac sodium in association with excimer laser phototherapeutic keratectomy. Topical diclofenac sodium, three times a day for 3 to 4 days, reduces the pain associated with excimer laser phototherapeutic keratectomy. This is analogous to the use of diclofenac sodium after excimer laser photorefractive keratectomy.3
1. Sher NA, Barak M, Daya S. Excimer laser photorefractive keratectomy in high myopia. Arch Ophthalmol 1992;110:935-943.
2. Arshinoff S1 D'Addario D, Sadler B, Bilotta R, Johnson TM. Use of topical nonsteroidal anti-inflammatory drugs in excimer laser photorefractive keratectomy. J Cataract Refract Surg 1994;20(suppl):216-222.
3. Sher NA1 Frantz JM1 Talley A1 Parker P1 Lane SS1 Ostrov C1 Carpel E1 Doughman D1 DeMarchi J1 Lindstrom R. Topical diclofenac in the treatment of ocular pain after excimer laser photorefractive keratectomy. Refract Corneal Surg 1993;9:425-436.
4. Tutton MK, Cherry PMH1 SundarRaj N1 Fsadni MG. Effîcacy and safety of topical diclofenac in reducing ocular pain after excimer photorefractive keratectomy. J Cataract Refract Surg 1996;22:536-541.
5. Förster W, Beck R1 Busse H. Design and development of a new 193-nanometer excimer laser surgical system. Refract Corneal Surg 1993;9:293-299.
Systemic Analgesic Use by Patients in Different Treatment Groups