Topical Non-Steroidal Anti-Inflammatory Drugs For The Management Of Pain After Photorefractive Keratectomy - A Network Meta Analysis
Published 2024 - 42nd Congress of the ESCRS
Reference: PP27.11 | Type: Free paper | DOI: 10.82333/xrmy-4x51
Authors: Dror Ben Ephraim Noyman* 1 , Adir C. Sommer 1 , Efrat Naaman 1 , Javier H. Gonzalez-Lugo 2 , Michael Mimouni 1
1Ophthalmology Department,Rambam Health Care Campus,Haifa,Israel;Ruth Rappaport Faculty of Medicine,Technion-Israel Institute of Technology,Haifa,Israel, 2Ophthalmology Department,Rambam Health Care Campus,Haifa,Israel
Purpose
Pain after photorefractive keratectomy (PRK) is a major concern for both patient and surgeon. While evidence has shown the value of including a topical non-steroidal anti-inflammatory drug (NSAID) in the postoperative regimen, no consensus is established for a preferable choice between them. Our goal was to compare the efficacy and safety of the different types of topical NSAIDs to supply surgeons with an evidence-based selection for their toolbox.
Setting
This was a network meta-analysis of randomized control trials (RCTs).
Methods
A search was done of PubMed, Scopus, and Embase, for RCTs reporting topical NSAIDs’ outcomes of corneal reepithelization, rescue analgesics intake, and subjective pain in days 0-3 after PRK (POD0-3). Studies were graded for risk of bias. Study data were extracted and Standardized Mean Differences (SMDs) were evaluated in a network meta-analysis in accordance with the Cochrane's guidelines, to which a frequentist approach model was fitted. Transitivity was assessed using the net-split method. Treatment effectiveness was ranked using forest plots based on comparison to placebo. P-scores (P) and league tables were used to examine combined direct and indirect comparisons.
Results
Out of 1540 studies identified, 27 were included. These encompassed 2286 patients across 11 countries, evaluating 7 distinct topical NSAIDs. Except for POD0, Flurbiprofen held the highest rank for reported pain throughout, significantly outperforming placebo on POD1 (P 0.874, SMD -1.19, 95%CI [-1.86, -0.52]), POD2 (P 0.882, SMD -1.05, 95%CI [-1.82, -0.27]), and POD3 (P 0.939, SMD -1.14, 95%CI [-2.1, -0.18]). Other NSAIDs were significantly better than placebo only on POD1 and POD0. Rescue analgesic intake analysis favored indomethacin (P 0.834, SMD -0.8, 95%CI [-1.33, -0.27]), ketorolac, and diclofenac. Reepithelization was slowed to different significances with all NSAIDs but flurbiprofen (P 0.991, SMD -0.7, 95%CI [-1.38, -0.03]).
Conclusions
Flurbiprofen was favorable in pain scores on typically postoperative painful days and reepithelization times. However, analgesics intake, a more objective outcome, suggested superiority of other NSAIDs. Inconsistencies may be explained by the small sample size. For clinical interpretation, NSAIDs' effect sizes should be taken into consideration.