Topical Pain Relief for Corneal Abrasion – A Systematic Review
March 2, 2021
Written by Clay Smith
Topical NSAIDs improved pain from corneal abrasion. The jury is out on other options per this review.
Why does this matter?
We have covered both a large retrospective study and a RCT looking at topical tetracaine for corneal abrasion. It works. That doesn’t seem to be in question (except in this systematic review). Is it safe? That is the key question this review can’t answer.
Would you like some drops so it no longer feels like there’s a red hot poker in your eye?
This was a systematic review and meta-analysis of 31 RCTs and 2 observational studies, 4,167 total patients, using various topical agents or patching for corneal abrasions. There was only enough combined data to draw firm conclusions on topical NSAIDs, which reduced pain at 24 and 48 hours. These patients also used less oral pain medication. The authors stated there was not enough evidence to show reduction in pain from topical anesthetics, cycloplegics, pressure patching, or a bandage contact lens. None of the treatments impaired healing, except perhaps pressure patching. I don’t recommend patching. They concluded there was insufficient evidence to determine if topical anesthetics reduced pain. Several individual studies have shown pain reduction, but apparently they could not be meta-analyzed. Call me anecdotal, but I’m a believer, having repeatedly seen these agents drastically reduce pain within seconds when I administer them in the ED. I was hoping to get clarity on the key question: are topical anesthetics safe? Instead, we still don’t know with certainty. The largest studies have shown no difference in healing or complications with topical anestetics, but none were powered to detect rare complications. Here is my bottom line. Topical NSAIDs work and appear safe. But even they can melt your patient’s eyeball, especially if given with topical steroids. I think this is a place for shared decision making when considering topical anesthetics. We know the risk is low. We are pretty sure pain control is significant. We want to avoid opioids. I would want to take the risk for myself or my family in the case of a simple, uncomplicated corneal abrasion and would use dilute proparacaine. Get the recipe on REBEL EM!
Salim Rezaie, REBEL EM, gives a tour de force on topical anesthetics for corneal abrasions you don’t want to miss, including how to mix up dilute proparacaine.
Topical Pain Control for Corneal Abrasions: A Systematic Review and Meta-Analysis. Acad Emerg Med. 2021 Jan 28. doi: 10.1111/acem.14222. Online ahead of print.