EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/511377
55 EW REFRACTIVE SURGERY May 2015 by Maxine Lipner EyeWorld Senior Contributing Writer Gaining perspective on PRK pain management Determining how to best find relief for patients W hen talking to pa- tients slated to under- go PRK, postoperative pain considerations are part of the agenda. But with something as subjective as pain management, just how effec- tive are the various regimens used to treat pain after PRK? That's what a study published in the Journal of Cataract & Refractive Surgery set out to consider, according to Ella G. Faktorovich, MD, director of Pacific Vision Institute, San Francisco. "There is a percentage of pa- tients who are not good candidates for LASIK, but they can still benefit from laser vision correction and they'll have great vision results; however, this always feels like you're describing a less popular cousin," Dr. Faktorovich said. "It's like you can go out on a date with a beautiful girl, LASIK; however, she's not avail- able right now, but PRK is available." The reason some patients might not be as excited about PRK as LASIK is that they have read on the Internet or heard from others that visual recovery is not as quick with PRK, and the procedure is more painful. However, when it comes to results, PRK and LASIK are indistin- guishable, Dr. Faktorovich said. As a result, there should be no reason why a patient who is motivated to undergo laser vision correction and who is a good candidate for PRK should not have the procedure done, she said. "I am passionate about trying to remove those barriers [to PRK]," Dr. Faktorovich said. "[Patients] come into the office and they're interes - ed in seeing better without glasses or contact lenses, and I don't want them to feel like they're getting an inferior procedure—I want them to be excited about it." Dr. Faktorovich said that pain relief regimens after PRK tend to vary from practitioner to practi- tioner. "A physician may have good experiences with one combination of drugs and another physician with a different combination," she said. She added that this could make it difficult for someone new to the surgery to decide what combination to use. To get a better idea of the effic - cy of certain drugs and drug proto- cols, investigators in this retrospec- tive study set out to consider all of the strategies that had been studied over the decades. Studying the literature They conducted a literature review of all of the randomized prospective studies of pain relief medication used after PRK, Dr. Faktorovich said. Included here were NSAIDS, anes- thetics, opiates, acetaminophen, gabapentin, and pregabalin. When investigators considered these, they found that all faired similarly. "One of the primary results was that all of the drugs are effective in reducing pain after PRK," she said. "There are minimal differences in efficacy between the drugs within each class of drugs." For example, when they examined 10 different nonsteroidal anti-inflammato y drops, based on what was published, there was little difference in efficacy between the types of nonsteroidals, Dr. Faktorovich explained. While they did determine the NSAID nepafenac and the topical anesthetic tetracaine were the most effective of all of the agents, the 2 unfortunately also shared a side effect—both had delayed re-epitheli- alization, she said. "Using both may be more effective than using either 1, but there was also a greater risk of delayed re-epithelialization," Dr. Faktorovich said. "I always thought I have often found the chiasm between patient and surgeon expectations of a successful operation to be very wide. When patients and their ophthalmologists start thinking more alike and the expec- tations are aligned, that is when patient satisfaction is the greatest. For most ophthalmologists a successful operation is viewed in terms of visual results and ana- tomic success. In my experience, patients expect good visual results but they also desire a comfortable procedure. In fact, pain is the rate-limiting factor for many patients' surgical expectations. In this article, Ella Faktorovich, MD, discusses the importance of pain control in patients undergoing PRK and the different treatment options to achieve this goal. Her statement that "pain is a barrier" for some patients to PRK is right on target. I com- pletely agree that the routine use of topical NSAIDs is a key therapeutic intervention. I have always tried to start my topical NSAID prior to surgery and will often supplement it with an oral NSAID as well. Stronger narcotics also play a role, but there is no cookbook for all patients as each patient has a different pain tolerance and response to treatment. The take-home message is that we as ophthalmologists need to be more compassionate to the needs of our patients and better understand the importance of managing and preventing pain, particularly in patients undergoing PRK. Eric Donnenfeld, MD continued on page 56 Refractive editor's corner of the world