EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/153099
18 EW CATARACT August 2013 Predicting and managing postop refractive pain by Vanessa Caceres EyeWorld Contributing Writer Who'll experience it, how to manage it, and when to suspect it's chronic O phthalmologists would like to think that patients don't experience pain after LASIK, but that's a myth, said Marguerite McDonald, MD, clinical professor of ophthalmology, New York University Langone Medical Center, New York; adjunct clinical professor of ophthalmology, Tulane University, New Orleans; and in practice, Ophthalmic Consultants of Long Island, Lynbrook, N.Y. Short-term pain after photorefractive keratectomy (PRK) is well known, but pain after LASIK is not discussed often, even though patients experience it, Dr. McDonald said. Still, she added that the pain after LASIK lasts just a few hours in most patients. Pain after refractive surgery deserves more attention, believes Todd P. Margolis, MD, Department of Ophthalmology and F.I. Proctor Foundation, University of California at San Francisco. "Ophthalmologists are not trained to evaluate or treat pain," he said. Sometimes, ophthalmologists misdiagnose chronic eye pain as dry eye, he said. What's really needed is more research into ocular pain, he added. Predicting pain So can you predict who among your refractive surgery patients will have pain-related issues? Patients who are particularly anxious are more likely to experience postop pain, said Audrey R. Talley Rostov, MD, Northwest Eye Surgeons, Seattle. Dr. Talley Rostov is not aware of literature on predicting refractive surgery-related pain, but general literature on postop pain notes that anxiety appears to be the biggest predicting factor in general surgery, as well as a younger age, genetic factors, other chronic pain conditions, and a history of depression or problems with anxiety. The patient's level of optimism—or lack thereof— also appears to make a difference, she said. A more optimistic patient will perceive better control of pain at one week after surgery, she explained. The NexisVision shield is used post-PRK to improve visual results and speed healing. Source: NexisVision On the other hand, patients who seek copious amounts of information on the internet about their medical care tend to experience less postop pain, Dr. Talley Rostov said. In her presentation at the Contact Lens Association of Ophthalmologists symposium at this year's ASCRS•ASOA Symposium & Congress in San Francisco, Dr. Talley Rostov shared a few ways to help patients manage their fear of pain, including establishing a good rapport, encouraging the practice of yoga breathing and meditation, holding patients' hands—literally and figuratively—during surgery, and prescribing pre- and postop medications to help with anxiety and pain management. Targeting pain with the medication regimen Some refractive surgeons steer clear of PRK because it usually requires several months of steroid use, and patients experience pain for a few days afterward, Dr. McDonald said. However, recent research into pain control, speeding up re-epithelialization, and managing steroid use more efficiently could make pain easier to manage after PRK, she said. Dr. McDonald has developed a steroid regimen where for healthy, nondiabetic patients, she'll prescribe oral and topical steroids at high doses for a week, but then stop them altogether. At one week, these patients return to her office with comfortable, white eyes, she said. Ice packs and chilled balanced salt solution are also crucial to reduce postop pain after PRK, Dr. McDonald said. She gives patients ice packs to use for a couple of days after PRK when they are resting at home. Dr. McDonald's PRK treatment regimen also includes comfort drops like 1/20th of 1% tetracaine, nonsteroidal anti-inflammatory drops, unpreserved artificial tears, acetaminophen, and Vicodin (hydrocodone/acetaminophen, AbbVie, North Chicago, Ill.). Dr. McDonald also tries new devices to target better pain control, such as the NexisVision shield (NexisVision, Menlo Park, Calif.), which is used post-PRK to improve visual results and speed healing. The shield is not yet commercially available, but Dr. McDonald has seen patients experience less discomfort and improved vision immediately after surgery. Focusing on chronic postop pain After refractive surgery, some ophthalmologists may diagnose a patient's pain problem as dry eye, when the patient is actually experiencing neuropathic or chronic pain, said Dr. Margolis, who sees a large number of ocular pain patients in his practice. Dry eye comes up in the diagnosis because the symptoms initially appear similar. "We have to change our way of thinking and start to realize that chronic ocular pain conditions exist and are proba- bly more common than we realize," he said. "We all have the duty to learn about these conditions and treat pain appropriately." To distinguish what might be post-refractive surgery dry eye from a chronic pain condition, Dr. Margolis recommends that ophthalmologists take a careful pain history, paying particular attention to morning pain that may get prompted by nighttime exposure. Surgeons should also assess adnexal structures, test for corneal sensation, evaluate tears, and stain the ocular surface. He encourages close listening to patients' pain complaints, as chronic pain sufferers may feel they are ignored. Patients with chronic pain problems may benefit from the use of systemic medications such as pregabalin and duloxetine as well as short-term use of the opiate tramadol. EW Editors' note: Dr. McDonald has financial interests with Allergan (Irvine, Calif.), Alcon (Fort Worth, Texas), Abbott Medical Optics (AMO, Santa Ana, Calif.), NexisVision, and other ophthalmic companies. Dr. Talley Rostov has financial interests with Allergan and Bausch + Lomb (Rochester, N.Y.). Dr. Margolis has no financial interests related to this article. Contact information Margolis: 415-476-1442, Todd.Margolis@ucsf.edu McDonald: 516-593-7709 x 222, Margueritemcdmd@aol.com Talley Rostov: 206-528-6000, atalleyrostov@nweyes.com