Managing Your Patients' PAIN
Surgeons offer tips and techniques for minimizing discomfort during cataract and refractive procedures.
BY CHRISTOPHER KENT, SENIOR ASSOCIATE EDITOR

Everybody wants surgery to produce an excellent outcome with no complications. But no matter how good the outcome, patients also want to avoid pain. Calvin Roberts, M.D., who practices in New York City, puts it this way: "The number one thing patients remember about their surgery is whether it hurt or didn't hurt. In fact, pain-free surgery is probably the best internal marketing I have in my practice."

Today, surgeons continue to find new ways to minimize patient discomfort. At the same time, many refractive surgeons are increasingly performing surface ablations, which potentially involve more post-surgical pain than alternatives such as LASIK.

For both of these reasons, we asked a number of surgeons to share their knowledge and experiences in pain management.

PHOTOGRPHER: JASON HETHERINGTON

Managing Pain with NSAIDs

NSAIDs are among the most widely used medications in ocular surgery, in part because they've been shown to serve multiple purposes. They help keep the pupil dilated, control inflammation during and after surgery, decrease the incidence of cystoid macular edema (CME), and help minimize pain.

However, while many doctors we interviewed have patients use an NSAID before surgery, some didn't perceive them as especially useful for preventing pain. So it's fair to ask: How much effect on surgical pain do NSAIDs really have?

The answer might depend on whether the NSAID is "pre-loaded" -- i.e., whether the patient takes the med for several days to build up the ocular level of the compound.

Dr. Roberts conducted a study to determine whether preloading made a significant difference. "We randomized our cataract patients into two groups," he explains. "One group started Acular LS four times a day, 3 days prior to surgery. The other group only got their NSAID on the day of surgery, along with their dilating drops. Each group had our standard application of 2% lidocaine HCl (Xylocaine) jelly right before surgery, but no intercameral lidocaine.

"After surgery we asked the patients to rate the amount of discomfort they experienced. Significantly fewer patients who had 3 days of pre-op Acular LS drops experienced any pain whatsoever. For this reason, I believe the combination of pre-loaded NSAID and 2% lidocaine at surgery gives cataract patients the best chance of remaining pain-free." (For more on NSAIDs, see "Comparing NSAID Options" on page 76.)

General Pain Management Tips

A host of general suggestions (many made in the context of cataract surgery) were offered by different surgeons. (For suggestions specific to surface ablation, see the next section.)

Tell your patients to keep their eyedrops in the refrigerator. Larry Patterson, M.D., medical director and surgeon at Eye Centers of Tennessee, underwent PRK, a surgery he performs routinely. "Cooling a drop down does two things," he notes. "One, it makes it easy to be sure the drop went into your eye, because it's cold. Two, it feels a whole lot better. Tears are much more soothing when they're cold."

Prepare the patient psychologically. Guy Knolle, M.D., who practices in Austin, Texas, says that the pain patients experience can have a lot to do with how much knowledge and confidence they have about the surgery. "I show patients a video that describes the vision they should expect post-op and tells them a little about the surgery and how it's going to work.

"I don't show them a video of the actual procedure unless they ask to see one," he adds, "although some patients need to know that this is a well-thought-out process! I also use a little humor sometimes, which lets the patient see that I'm relaxed about the whole thing."

Use chilled BSS to rinse during surgery. Several surgeons reported that this lessens patient discomfort.

After cataract surgery, don't overprescribe pain meds. "As a rule, we never prescribe narcotics or strong pain meds after cataract surgery," says Dr. Patterson. "Our experience with the vast majority of patients has been that there's no pain involved if the surgery is done properly. We tell patients that if they're having some discomfort, it's okay to take something like Tylenol. However, if they're having significant discomfort in the hours after surgery, we want them to come in. The odds are they're having a pressure spike."

Follow-up with the patient. Don't just assume the patient will call you if there's a problem. Vickey Hawkins, COA, surgical coordinator at Eye Centers of Tennessee, offers the following suggestions:

• Have the doctor or a staff member call each surgical patient the afternoon after their procedure to see how they're doing since the topical anesthesia has worn off. Calling is good for patient relations, and also may help those patients who really are in pain but didn't want to bother the doctor.
• Make sure patients are told to call if they have severe pain, which can be an indication of a complication.

Make sure patients don't take unprescribed narcotics. Ms. Hawkins notes that patients may have drugs left over from another procedure or injury. Patients need to know that taking these drugs can mask pain that the ophthalmologist needs to know about.

Managing Pain After Surface Ablation

The trend toward more surface ablation in refractive surgery is clear. "I've spoken to doctors who say they don't do PRK, just LASIK," notes Dr. Patterson. "To me, that doesn't make any sense. What do you do with patients who have thin corneas and large pupils? The only alternative is to create a small optical zone, or ablate more tissue than you should. If you've got a routine LASIK practice, at least 10% of your patients probably need surface ablation."

Of course, one of the biggest problems with surface ablation is post-surgical discomfort. Here are a number of strategies for alleviating pain associated with PRK, LASEK and epi-LASEK, suggested by the surgeons we interviewed.

Try a Cox-2 inhibitor. Thomas Claringbold, D.O., used to have patients take OTC Motrin (Ibuprofen) before and after surgery. Then, one of his patients reported that he had taken some Vioxx (rofecoxib) that was left over from his treatment after a skiing accident -- and it made a big difference. (Vioxx is an orally-taken Cox-2 inhibitor in the NSAID family, often prescribed for arthritis pain.)

"Once I saw the potential, I had patients start Vioxx 50 mg on the day of surgery." says Dr. Claringbold. "Later, I spoke to a rheumatologist, who said it's more effective if you get blood levels up for about 72 hours. So now I have patients start 3 days before surgery and continue for 4 days after.

"For comparison, I had the patients fill out pain questionnaires, and the Vioxx was definitely an improvement over the Motrin."

If you do plan to have patients use an Ibuprofen product such as Motrin for surgical pain, Dr. Claringbold advises that you have them take prescription strength, not the standard OTC dosage. "To be effective in this situation, patients need about 800 mg of Motrin (four OTC pills) every 6 hours."

Try using an alpha-2 agonist before surgery. Dan Durrie, M.D., who practices in Overland Park, Kan., instills one drop of brimonidine tartrate (Alphagan) 30 minutes before the procedure. "Doing this vasoconstricts the conjunctiva, making the eye white; it minimizes inflammation during the procedure. This is a pain issue, because the less inflammation and conjunctival reaction the patient has, the better he feels afterward."

Use a BSS "popsicle." "Before I remove the epithelium for LASEK," says Dr. Durrie, "I cool the surface of the eye with a frozen BSS sponge, almost like a popsicle, which we prepare ahead of time under sterile conditions. I hold it against the cornea for 10 seconds to cool the eye. Then I remove the epithelium, do the laser, and cool the cornea down again for another 10 seconds with the popsicle."

Dr. Durrie notes that his current strategy, which involves pre-op drops of brimonidine tartrate and ketorolac, the BSS "popsicle" during surgery, post-op ketorolac and a well-fitting contact lens, seems to work very well. "Before I began using this regime, almost everybody went out and filled the optional narcotics prescription I'd give them after surgery, and they complained the next morning about the discomfort. Now I don't hear any complaints about discomfort during the first 24 hours, and most patients don't fill their prescription for a narcotic -- or even an NSAID."

Provide patients with comfort drops. Dr. Patterson notes that discomfort following PRK can come in intermittent waves . . . it doesn't always get better gradually. He offers his patients "comfort drops" made from artificial tears with proparacaine added (one part proparacaine, nine parts tears). "Some studies indicate that proparacaine in dilute form doesn't retard epithelial healing," he notes. "During the first 2 or 3 days after PRK, when you suddenly have a wave of pain, these drops give you a little respite. We tell people not to use them more than once an hour."

Dr. Claringbold also reports that he's begun providing a dilute solution of tetracaine for some patients following surgery. "I only offer this to patients who seem likely to have more pain," he notes, "those who aren't used to wearing contacts, or are very sensitive during the exam, or who call up after surgery and complain of discomfort."

Choose the right contact lens. "Selecting the right post-surgery contact lens is very important," says Dr. Claringbold. "The lens has to be mobile and get a lot of oxygen. I almost always use the Soflens 66 from Bausch & Lomb with a flat median base curve. When I first started I used the contact lenses the laser companies provided, but I found that patients had quite a bit more pain with those."

If you prescribe a narcotic for post-op pain, suggest using it as a sleep aid for the first night or two after surgery. After undergoing PRK, Dr Patterson found this was the best use of the post-op narcotic. "For the first night or two your eyes are uncomfortable, which can make it hard to sleep. Even if you don't want to use it at other times, the narcotic can help you get to sleep."

After PRK, advise patients to wear sunglasses during the day and a protective shield or goggles at night. Following his surgery, Dr. Patterson accidentally rubbed one eye and pushed the therapeutic contact lens off. "The pain was incredible," he says. "After LASIK we emphasize not rubbing your eye to avoid dislodging the flap, but dislodging a contact lens, while it doesn't hurt anything, is awfully painful. It made me realize why it was so hard for PRK to gain acceptance early on, before people used NSAIDs and contact lenses."

Advise patients to avoid driving for a week. "The problem isn't being unable to see," explains Dr. Patterson. "You may be fine in the house, but when you get in the car where it tends to be very dry, your cornea will quickly dry out and you'll have to pull over just from the discomfort."

Consider offering other surgeries. Some surgeons have observed that when surface ablation is called for, LASEK may be more comfortable for patients than PRK. Also, surgeons who have tried "epi-LASEK" report that this may be less painful than standard LASEK. (Instead of using alcohol to remove the epithelium, epi-LASEK uses a disposable, oscillating, PMMA block to separate the soft part of the corneal surface tissue from the stiffer tissue as it crosses the eye, creating a very thin, hinged epithelial flap.) However, the number of patients who have had epi-LASEK is still too small to draw any solid conclusions.