Ophthalmic NSAIDs for Eye Care

Nonsteroidal anti inflammatory drugs inhibit cyclooxygenase activity and reduce prostaglandin mediated inflammation, making them valuable for managing pain and surface inflammation without the steroid related risks of intraocular pressure elevation or immunosuppression. They are routinely used after cataract or refractive surgery, during episodes of corneal abrasion related pain, and for adjunctive comfort in selected inflammatory conditions. Appropriate use can shorten recovery time, improve visual quality during healing, and enhance patient satisfaction with postoperative care.

By blocking COX 1 and COX 2 pathways, topical NSAIDs lower prostaglandin levels within ocular tissues, which decreases hyperemia, edema, and nociceptor sensitization. Clinical indications include postoperative inflammation and pain control, prevention or treatment of cystoid macular edema after cataract surgery, and symptomatic relief in superficial injuries. They are less effective than steroids for deep uveal inflammation and should not be relied on as monotherapy for uveitis or scleritis. Understanding their ceiling effect on inflammation helps clinicians decide when to escalate to steroids or add other agents.

Differences in lipophilicity, tissue penetration, dosing frequency, and preservative systems influence drug selection. Bromfenac and nepafenac offer once or twice daily dosing that can improve adherence, while ketorolac remains widely available and cost effective. Diclofenac provides strong analgesia but has been associated with higher rates of corneal melt in compromised corneas. Match the agent to the surgical protocol, surface status, and patient cost sensitivity to optimize both safety and adherence.

Prolonged or frequent dosing, especially on a compromised epithelium, increases the risk of corneal melt, epithelial defects, and delayed wound closure. Patients with dry eye disease, epithelial basement membrane dystrophy, neurotrophic keratitis, or a history of herpetic disease warrant extra caution. Limit duration to the evidence supported window, reassess epithelial integrity at follow up, and discontinue immediately if epithelial breakdown or severe pain develops. Educate patients to report worsening discomfort, photophobia, or vision changes promptly.

Start NSAIDs one day before or on the day of surgery when protocols call for CME prophylaxis and continue for the recommended postoperative period, often four to six weeks. For abrasions or superficial injuries, short courses of one to three days can provide comfort while epithelial healing proceeds. When pairing with steroids, stagger instillation by at least five minutes to avoid washout and to reduce cumulative preservative exposure. Document start date, intended duration, and reassessment plan so tapering or cessation occurs on schedule.

Inform patients that temporary stinging on instillation is common and that vision may blur briefly. Stress adherence to the prescribed frequency since under dosing diminishes benefit and overuse increases risk. Discuss generic versus branded options when cost is a barrier and consider preservative free formulations for heavy users or sensitive surfaces. Schedule follow up visits that align with the healing timeline to confirm symptom resolution, check the epithelial surface, and adjust therapy if inflammation persists.