Diclofenac Ophthalmic Solution and Other NSAIDs Offer Effective Treatment for Eye Pain
Probably not. Antihistamines, artificial tears, and topical steroids are the most common eye care agents—but NSAIDs still belong on the team. They’re approved as first-line treatment following cataract surgery, but they’re also recommended to relieve seasonal allergic conjunctivitis and to treat several common eye conditions. Pharmacists have an important role to fill in helping patients understand how and why NSAIDs are used—especially when it comes to off-label uses. Patients need your expertise to help them compare costs and choose the best option.
Ophthalmic NSAIDs in Primary Care
Ophthalmic NSAIDs may have a small role in primary care, but they’re still great for pain relief, helping reduce inflammation and alleviate itchy eyes. But since most ophthalmic uses for NSAIDs in the primary care setting are off-label, clinicians must rely on experience to guide them toward the best options, especially when they are prescribing for children. NSAIDs are recommended for the following:1
Allergic conjunctivitis: While ketorolac is the only NSAID currently approved to relieve itching caused by seasonal allergies, diclofenac sodium and bromfenac are also effective. They can be administered together with other ophthalmic medications such as antibiotics, alpha-agonists, and beta blockers, but patients with asthma or hypersensitivity to aspirin may experience adverse effects.
Corneal abrasions: Corneal abrasions are the third most common cause of red, irritated eyes. Patients present with eye pain, tearing, sensitivity to light, and the feeling that a foreign substance is in their eye. First-line treatment consists of topical antibiotics plus topical NSAIDs for pain relief, such as diclofenac 0.1 percent or ketorolac 0.4 percent. Topical NSAIDs may be used for short-term therapy in children with corneal abrasions.
Cystoid macular edema (CME): The name accurately describes the condition, in which cyst-like areas of fluid develop in the macula, causing retinal swelling or edema. CME commonly occurs in patients with age-related macular degeneration, uveitis, epiretinal membrane, and especially diabetic retinopathy. Up to 6 percent of non-diabetic people develop CME, compared to an estimated 56 percent of diabetics.2 NSAIDs applied alone or together with steroids lower the odds of diabetic and non-diabetic patients developing CME.
Topical NSAIDs can also be used as part of the therapeutic regimen for:
- Keratitis-related photophobia
- Treating or preventing Inflamed pterygia and pingueculae
- Helping patients adapt to punctal plugs
- Scleritis, when used to supplement oral NSAIDs
- Recalcitrant uveitis, as a supplement to steroids
Topical NSAIDs Following Cataract Surgery
Ophthalmic NSAIDs are FDA-approved for use in eye surgery, where they’re the accepted standard of care for postoperative management of cataracts. They’re also used during surgery to control inflammation and help maintain papillary dilatation. Various NSAIDs are also FDA-approved to treat the following issues:3
- Inflammation and ocular pain following cataract extraction – bromfenac, diclofenac, ketorolac, and nepafenac.
- Pain and photophobia post-corneal refractive surgery – diclofenac
- Ocular pain, burning and stinging following corneal refractive surgery – ketorolac
- Inhibition of intraoperative miosis – flurbiprofen
When cystoid macular edema develops following cataract surgery, it’s referred to as pseudophakic cystoid macular edema (PCME) or Irving-Gass Syndrome. In spite of advances in surgical techniques, PCME is still a common cause of reduced vision after cataract surgery. Some cases of PCME become chronic, affecting vision and proving difficult to treat. One of the biggest benefits of topical NSAIDs is their off-label use to prevent PCME.
Pharmacists should target patients who have a high risk for PCME and advise them to seek appropriate treatment before undergoing cataract surgery. Keep a particular eye out for these risk factors:
- Diabetes – All patients with diabetes have double the risk of PCME, and the odds go up in those with retinopathy. Retinopathy and macular edema should be treated prior to cataract surgery.
- Uveitis – Patients with uveitis are at increased risk for PCME. Ocular inflammation should be controlled for at least three months before cataract surgery.
- Other eye conditions – The presence of epiretinal membrane, vitreomacular traction, and retinal vein occlusion boost the chance of developing PCME.
- Topical prostaglandin use – Glaucoma patients being treated with topical prostaglandins should be aware of their higher risk for PCME.
NSAIDs carry the risk of side effects like stinging, burning, conjunctival hyperemia, and allergy. If your patients experience adverse effects on the ocular surface, they may do better with nepafenac, since its effects are intraocular.
Comparing Costs and Efficacy of NSAIDs
The newcomers nepafenac and bromfenac are sometimes called superstar ophthalmic NSAIDs for one reason—they’re only applied once daily. Unfortunately, they also carry a significantly higher price tag. And at present, there’s no evidence to suggest one topical NSAID is better than another in controlling postoperative inflammation. Meanwhile, a study published in August 2016 found that diclofenac and nepafenac had similar high tolerability, making diclofenac a more affordable alternative.4 As patients step into this confusing mix of information—with so many different NSAIDs and the ongoing need for quality evidence—pharmacists should reach out to discuss the options and offer expert guidance.
Pharmaceutica North America provides high-quality prescription and bulk active pharmaceutical ingredients, including a variety of NSAIDs such as diclofenac and flurbiprofen. Contact us today to talk about how we can support all your pharmaceutical needs.
- “2016 Clinical Guide to Ophthalmic Drugs, May 2016, https://www.reviewofoptometry.com/CMSDocuments/2016/5/dg0516i.pdf ↩
- “Evaluation and Management of Corneal Abrasions,” January 2013, http://www.aafp.org/afp/2013/0115/p114.html ↩
- “Ophthalmic Anti-Inflammatories Therapeutic Class Review,” May 2016, http://www.hhsc.state.tx.us/news/meetings/2016/dur/072916/4p.pdf ↩
- “Comparison of the Tolerability of Diclofenac and Nepafenac,” August 2016, http://www.ncbi.nlm.nih.gov/pubmed/27513223 ↩