Combination therapy alleviates surface ablation discomfort

With surface ablation procedures becoming more common, surgeons have developed a combination therapy management approach including a fluoroquinolone antibiotic, a nonster-oidal anti-inflammatory drug (NSAID), and a steroid to prevent infection and reduce pain.

"To prevent infection you want to use the most powerful antibiotics, such as those with fast kill curves and the lowest minimum inhibitory concentration (MIC)," said Robert W. Snyder, MD, PhD, a LASEK surgeon and professor of biomedical engineering, University of Arizona, Tucson.

To prevent infection, he uses the fourth-generation fluoroquinolone gatifloxacin ophthalmic solution 0.3% (Zymar, Allergan) immediately postop and q.i.d. until the surface has healed to prevent infection.

"With the anti-inflammatory drugs, physicians should consider ones that are proven and time-tested to be safe and
effective as both an anti-inflammatory and an analgesic," Dr. Snyder continued. "Keto-rolac tromethamine ophthalmic solution 0.4% (Acular LS, Allergan) and prednis-olone acetate (Pred Forte, Allergan) seem to work very well in LASEK for minimizing inflammation, postoperative haze, and postoperative discomfort and pain."

For Epi-LASIK and LASEK procedures, his pain prevention strategy also includes the use of 200 mg of celecoxib (Celebrex, Pfizer) p.o. the day before surgery; 400 mg the day of surgery; and 200 mg for several days postoperatively. Dr. Snyder noted that celecoxib used off-label is a highly effective analgesic that helps minimize patient discomfort.

When the patient arrives at the laser center Dr, Snyder starts 1 drop of ketorolac tromethamine 0.4% and non-preserved 0.5% tetracaine × 5. This regimen, in addition to using 20% ETOH prewarmed to 37° C, aids in separation of the epithelium during the LASEK and the tetracaine also provides excellent anesthesia while the ketorolac tromethamine 0.4% aids in postoperative analgesia. He continues the ketorolac tromethamine 0.4% q.i.d. for 2 or 3 days until the patient is comfortable again.

For alcohol-assisted LASEK, Dr. Snyder's postoperative regimen is gatifloxacin, ketorolac, and prednisolone each four times daily.

"I can usually eliminate ketorolac by the third day and stop the prednisolone and the gatifloxacin in 1 week," he added. "The ketorolac is very effective at minimizing postoperative light sensitivity and pain."

Ensuring patient comfort

In addition to the pharmacologic selection, other steps taken before and during surgery also contribute to patient comfort and good outcomes. He emphasizes the use of prewarmed ethanol 20% for 20 to 30 seconds max when performing LASEK. Dr. Snyder also emphasized that the selection of a bandage contact lens is important and added that he soaks these lenses in balanced salt solution (BSS) before placing them onto the eye.

Stephen E. Pascucci, MD, a corneal disease and refractive specialist in Bonita Springs, FL, performs both classic LASIK and what he refers to as advanced surface ablation, which is essentially PRK. He described his approach to surface ablation procedures.

"We've looked at a variety of different means over the years to try to preserve the epithelium in patients in whom we were not planning to do LASIK, by making epithelium flaps or doing LASEK," Dr. Pascucci said. "We found that typically when we tried to do that, more often than not, the epithelium would eventually slough, and we were back to a PRK procedure one way or the other."

During these procedures, both mechanical- and alcohol-based methods of removing the epithelium have been used, with little difference observed in the rate of epithelialization or postoperative discomfort.

He also uses a combination of three agents preoperatively and postoperatively as well as various other non-pharmaceutical strategies.

BSS 'popsicles'

For example, he has also found that BSS "popsicles" enhance patient comfort, although the effect is more subjective than measurable. These are sponges soaked in BSS, frozen, and placed on the cornea for about 30 seconds at the end of treatment.