Ketorolac tops topical NSAIDs preop
- Researchers comparing preoperative cataract-surgery eye drops reported ketorolac beat nepafenac and bromfenac on drug levels inside the eye and on prostaglandin suppression. - In one 132-patient masked trial, 61.9% of ketorolac-treated eyes had undetectable prostaglandin E2, versus 17.5% with nepafenac before phacoemulsification surgery. - Later reviews found mixed clinical advantages despite those lab markers, tempering protocol changes. (plos.org)
Cataract surgery often starts with anti-inflammatory eye drops meant to keep the pupil stable and blunt the chemical signals that drive swelling and pain. (ophthalmologytimes.com) Those signals include prostaglandin E2, a molecule the eye releases when tissue is irritated during surgery. Topical nonsteroidal anti-inflammatory drugs, or NSAIDs, try to shut that pathway down before the first incision. (springer.com) (pubmed.ncbi.nlm.nih.gov) The head-to-head data behind this story came from masked, randomized studies presented by Frank A. Bucci Jr. comparing ketorolac with nepafenac and bromfenac in patients undergoing phacoemulsification. (ophthalmologytimes.com) (springer.com) In the ketorolac-versus-nepafenac trial, 132 patients used drops four times daily for two days before surgery, then a pulse regimen just before the procedure. Mean aqueous drug levels were 1,079.1 ng/mL with ketorolac and 353.4 ng/mL with amfenac, nepafenac’s active form. (pubmed.ncbi.nlm.nih.gov) (ajo.com) That same study found prostaglandin E2 was below the assay’s detection limit in 26 of 42 ketorolac eyes, versus 7 of 40 nepafenac eyes. Mean prostaglandin E2 was 159.5 pg/mL with ketorolac and 322.0 pg/mL with nepafenac. (pubmed.ncbi.nlm.nih.gov) A later three-arm study randomized 121 patients to ketorolac 0.45%, bromfenac 0.09%, or nepafenac 0.1% at labeled preoperative dosing. Mean prostaglandin E2 concentrations were 224.8 pg/mL for ketorolac, 288.7 pg/mL for bromfenac, and 320.4 pg/mL for nepafenac. (springer.com) Those measurements are surrogate markers, not the same thing as what a patient sees or feels after surgery. They estimate how much drug reached the aqueous humor, the fluid in the front of the eye, and how strongly the drop blocked a key inflammatory pathway. (pubmed.ncbi.nlm.nih.gov) (springer.com) The clinical picture is less one-sided. A 2017 meta-analysis of 11 randomized trials covering 1,165 patients found nepafenac and ketorolac were equally effective on postoperative inflammation, macular edema, visual recovery, and intraoperative pupil dilation, while nepafenac had better tolerability on conjunctival redness and discomfort. (plos.org) Another randomized cataract study published in the British Journal of Ophthalmology compared ketorolac 0.4%, nepafenac 0.1%, and placebo for cystoid macular edema prevention after phacoemulsification, showing both NSAIDs reduced macular changes versus placebo rather than establishing a clear winner between the two drugs. (bmj.com) So the case for ketorolac is strongest on preoperative pharmacology: higher measured intraocular levels and lower prostaglandin E2 in these trials. Whether that should rewrite a residency protocol depends on what a service values more — lab suppression, patient comfort, dosing convenience, or head-to-head postoperative outcomes. (ophthalmologytimes.com) (plos.org)
