Using NSAIDs to
Full Advantage

BY WILLIAM TOWNSEND, O.D.
JULY 1996

I was surprised to learn that many optometrists have never heard of managing viral keratoconjunctivitis, particularly epidemic keratoconjunctivitis (EKC), with topical nonsteroidal anti-inflammatory drugs (NSAIDs). Although NSAIDs may not be specified in the FDA protocol as a treatment for this condition, they have certainly gained popularity in recent years.

Before the introduction of topical NSAIDs, steroids were the only means for controlling the inflammation and pain associated with EKC. The problem with using steroids, however, is that the infiltrates often recur after discontinuing the drops.

NSAIDs block the cyclooxygenase branch of the arachidonic acid pathway. Almost all living cell membranes contain arachidonic acid, and any break in the integrity of the cell membrane, whether physiologic (as in mast cell degranulation), traumatic, photic (UV exposure) or chemical, leads to the release of this substance.

The enzyme cyclooxygenase converts arachidonic acid into prostaglandin, which enhances pain. By preventing its synthesis via steroids or NSAIDs, we can reduce patient discomfort. Blocking the conversion of cyclooxygenase into prostaglandin also reduces miosis, hyperemia, breakdown of the blood aqueous barrier and IOP elevation.

FOREIGN BODY REMOVAL

One of the most practical clinical uses for NSAIDs is in corneal foreign body removal. I'm sure we've all seen patients develop mild to severe uveitis one day after foreign body removal. Removing a foreign body, particularly with an Alger brush or corneal burr produces significant painful trauma to epithelial cell membranes. Two drops of a topical NSAID before and after foreign body removal can significantly reduce, and in many cases eliminate, this response. This regimen has greatly improved our rate of 'middle of the night' calls after foreign body removal. Oral NSAIDs are also helpful in moderating the pain associated with foreign body removal, we typically prescribe Advil, 400mg, every four hours the first day.

Remember that oral NSAIDs are contraindicated in individuals with a history of peptic ulcers or severe renal disease.

PHOTIC INJURY

Photokeratitis presents another opportunity to combine oral and topical NSAID regimens to maximize patient comfort. When individuals fail to use adequate sun protection, they may present with an exquisitely painful, and usually bilateral, condition anywhere from eight to 12 hours after exposure. Photokeratitis patients benefit from the use of topical and oral NSAIDs. However, topical NSAIDs have an unfortunate side effect. The preservatives used in these medications retard healing, so in cases of photokeratitis, you should limit their use to no more than one drop per eye, four times a day.

ALLERGIES

The benefits of NSAIDs to treat ocular allergy are well known. Acular has been approved for this use for some time. Another application for NSAIDs is to manage giant papillary conjunctivitis (GPC). Several studies have shown that NSAIDs are effective in reducing the signs and symptoms of this condition. Adding an NSAID often helps relieve the itching, mucous discharge and papillary hypertrophy associated with GPC. We should point out, however, that in a work by Wood et al., it took Suprofen, the NSAID used in their study, three to four weeks to achieve a statistically significant level of symptomatic reduction and resolution of papillae. CLS

Dr. Townsend is in private practice in Canyon, Texas, and is a consultant at the Amarillo VA Medical Center.