Written by Clay Smith
Spoon Feed
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!
Another Spoonful
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.
Source
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.
You’re bolder than me. While you’re probably right, I haven’t met an ophthalmologist yet who thinks they’re safe, and will absolutely blame an ulcer on its use. I’ve had many a corneal abrasion and while they’re painful, it’s 24 hours of discomfort. Ibuprofen and a hydrocodone or two for the patient to sleep should be sufficient. I’m not going to go against the specialist here with the conclusive data to support me
I was gifted with a corneal abrasion, post cataract surgery, my 1st surgery was my very low vision eye, no problem. Next week, gift on my dominate eye. I had a total shoulder replacement 2 years prior, I was given adequate pain control for that surgery, but my cornea “ nothing will help”, numbing drops for the diagnosis, and then patching and artificial tears. I could see clearer shadows in my low vision eye, and my husband had to patch me, lead me around, while my sick leave account dropped. I get back to work after a week, ( second surgery), I am an acute care inpatient RN, and we had a patient with a corneal abrasion on a Morphine PCA!!!!. My Ophthalmologist gave me artificial tears, only, I have no substance abuse issues, just wanted something to take the edge off to be able to sleep. I can’t say I would want to risk an ulcer, no ophthalmologist, and I have seen several, have ever advised laser surgery to correct my vision. Cataract removal and ocular implants were the only thing ever recommended. I am astounded that other MD’s at least try to take the edge off of such excruciating pain, and others don’t! The pain is real, in no way am I advocating a PCA for a corneal abrasion, buts thanks for researching a real problem!