Ophthalmic NSAIDs: Post-Op Use, Pain Relief, and Safety
What topical NSAIDs do and how they differ from steroids
Topical non-steroidal anti-inflammatory drugs (NSAIDs) inhibit cyclooxygenase (COX-1 and COX-2), which reduces prostaglandin synthesis in ocular tissues. Prostaglandins contribute to pain, miosis, and increased vascular permeability, especially around ocular surgery.
Unlike topical corticosteroids, NSAIDs do not typically raise intraocular pressure and do not provide the same broad immunosuppression. Their main value is targeted prostaglandin suppression for analgesia and cystoid macular edema (CME) risk reduction. They are commonly paired with topical steroids, which are strong for anterior segment inflammation but are less direct at blocking prostaglandins.
Common clinical indications
- Cataract surgery: Reducing post-operative pain and photophobia, supporting CME prevention, and helping limit prostaglandin-driven miosis as part of a coordinated perioperative regimen with a steroid.
- Refractive surgery (PRK and LASIK): Short-term pain control early after surgery, especially after PRK with a bandage contact lens.
- Corneal abrasion or foreign body removal: Very limited duration use for significant acute discomfort, with close attention to epithelial healing and follow-up.
- Selected surface inflammation and allergy: Occasional adjunctive use for discomfort (for example ketorolac), though antihistamine and mast-cell stabilizer drops remain first-line for allergic conjunctivitis.
Choosing an agent in practice
Selection is usually based on the clinical goal (perioperative CME prophylaxis vs short-term corneal pain), dosing convenience, and surface tolerance.
Bromfenac: Often used in perioperative care because it can be dosed less frequently and is commonly well tolerated.
Nepafenac: A prodrug converted intraocularly to amfenac, used in cataract surgery regimens with the intent of supporting posterior segment anti-inflammatory effect and CME prevention.
Ketorolac: Widely available and effective for short-term pain control, though stinging and more frequent dosing can limit tolerability for longer courses.
Diclofenac and older formulations: Effective, but some reports associate use in compromised corneas with a higher risk of epithelial toxicity. Use cautiously and avoid prolonged dosing on non-healed surfaces.
Safety and corneal toxicity
Most patients tolerate topical NSAIDs well, but rare cases of corneal thinning and melt have been reported, particularly in eyes with pre-existing surface compromise such as neurotrophic keratopathy, severe dry eye, autoimmune disease, prior herpetic keratitis, or large epithelial defects. Risk increases with prolonged dosing on a non-healed cornea. Practical safeguards include using the shortest effective course on open defects, avoiding extended NSAID use in high-risk corneas, and discontinuing the medication if worsening pain, persistent epithelial defects, or signs of progressive thinning occur.
How NSAIDs fit into perioperative regimens
In surgical care, NSAIDs work best as part of a coordinated plan that also includes topical steroids, lubrication, and, when needed, systemic analgesia. Clear instructions about dosing, expected duration, spacing between drops, and stop criteria help reduce overuse and minimize epithelial toxicity while preserving pain relief and CME risk reduction. When patients have significant ocular surface disease, clinicians often individualize the plan to prioritize healing and comfort.