What A Pain In The E%E! Pain Management for the OD. Jane Ann Grogg, O.D., F.A.A.O. Indiana University School of Optometry

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1 What A Pain In The E%E! Pain Management for the OD Jane Ann Grogg, O.D., F.A.A.O. Indiana University School of Optometry

2 History Qualify sharp boring foreign body dull Extent Mild to severe 1 to 10 Establish the source of the pain. Treat the source ->Treat the pain

$Ocular Pain: Common Sources Corneal (Trigeminal, CN V) S/P foreign body removal S/P refractive$ Infiltrative/ulcerative keratitis Thermal keratitis REE Thygeson s SPK SLK Anterior uveitis

Infiltrative/ulcerative keratitis Thermal keratitis REE Thygeson s SPK SLK Anterior uveitis

3 Ocular Pain: Common Sources Corneal (Trigeminal, CN V) S/P foreign body removal S/P refractive surgery procedures UV keratitis CL related issues Over wear H2O2 Phylectenulosis Infiltrative/ulcerative keratitis Thermal keratitis REE Thygeson s SPK SLK Anterior uveitis pain Post surgical pain Trauma related pain Sudden IOP elevation Periorbital pain Sinus Blunt trauma Optic Neuritis

4 Clinical Symptoms & Signs Symptoms Pain Tearing Photophobia Signs Ptosis Miosis Perilimbal injection Anterior chamber cell/flare Eyelid edema The uveitis hold

5 Route of administration for ocular pain management Topical Oral Mechanical

6 Topical Pain Management Generally, the first line of defense. Advantages: Fewer systemic side effects Fewer interactions Higher concentration at sight of source of pain Cycloplegic agents Topical NSAIDS Topical steroids

7 Diluted proparacaine CAUTION: risk of toxicity and potential abuse. NOT the standard of care! May be used for confirmation of source of pain Aid in cooperation for the examination. Short acting Epithelial disruption Watch that the bottle doesn t disappear! ER errors

8 Cycloplegic Agents Often ocular pain is associated with an inflammatory component Often, there is a perfect storm : corneal + inflammation Blocks acetylcholine thus giving mydriasis and paralyzing the CB Function: Comfort- relieve pain by paralyzing the ciliary spasm Reduce leakage- by stabilizing the blood aqueous barrier, prevent further protein leakage, which reduces anterior chamber inflammation. Prevent posterior synechiae which can lead to iris bombe & elevated IOPs- keeps the pupil moving

9 Cycloplegic Agents Considerations: duration and extent of cycloplegia and mydriasis how heavily pigmented the iris is how much inflammation is present Short acting to long acting agents Determine on a case by case basis given etiology and confounding factors

10 Cycloplegic agents Cyclopentolate 0.5%, 1%, 2% Short-acting In office until patient can pick up prescriptions Mild pain, minor trauma Homatropine 5%, 2% Available for office supply but not as RX BID to QID Consider 2-4 gtts in office This may need to be continued on an in office basis for 2-3 days. Cycloplegic recovery in approximately 3 days Scopolamine.25% BID Atropine 0.05%, 1%, 2% BID to TID dosing Most potent cycloplegic agent Lasting days

11 Precautions CNS effects of Scopolamine & Cyclopentolate increased with multi doses Cardio effects of phenylephrine (10%) especially the elderlymonitor B/P Useful for breaking PS In office use only Posterior synechia secondary to long term use of Scopolamine & Atropine use Goal Keep the pupil a little mobile Prevent synechia in the dilated state

12 Topical NSAIDS FDA approval for post-op inflammation Surgical centers MOA: inhibition of prostaglandin synthesis by competing for receptors and blocking cyclooxygenase (COX) COX: an enzyme responsible for the production of inflammatory mediators (prostaglandins). These drugs reduce inflammation and induce an analgesic effect. Work further down the inflammatory cascade than steroids to decrease pain and inflammation. Documented cases of delayed wound healing and corneal melts. Precaution in ASA allergy for cross-sensitivity reaction

13 Original NSAID versions: Acular (ketoroac), QID *0.5%, historical: allergy LS 0.4% Acuvail 0.45% unit dose $$ Preservative free! Individual ampules Perioperative use BID, one day prior to surgery *Voltaren (diclofenac 0.1%), QID Both burn upon instillation (some recommend refrigeration). Both show decreased corneal sensation. *generic

14 Newer NSAID formulas: Nevanac (nepafanac 0.1%), TID A prodrug: nepafenac at initially delivery to the corneal surface then converted enzymatically to COX-inhibitor amfenac as it penetrates the intraocular tissues. Ilevro (nepafanac 0.3%) once daily dosing Bromday (Bromfenac 0.09%) ONCE DAILY Original formula known as Xibrom Prolensa (Bromfenac 0.07%) Once daily

15 NSAIDS: Helpful hints Can be used in office for initial pain management treatment Uses in pain management S/P cataract surgery (CME) S/P refractive surgery S/P FB removal Corneal abrasion Photophobia Supplement in uveitis, episcleritis, scleritis, pingeculitis Caution in compromised corneal epithelium: corneal toxicity delayed wound healing corneal melts Caution in RA patients and diabetics Limit use to approximately 1 week (with the exception of CME) Pay attention to poorly healing corneal wounds Stick to recommended dosages

16 Corticosteroid use in pain management Corneal pain S/P FB UV keratitis Infiltrative/ulcerative keratitis Thermal keratitis REE Thygeson s SPK Uveitic pain CL related pain Overwear Hydrogen peroxide burn Phylectenulosis Post surgical pain Trauma related pain SLK

17 Topical steroids Role in: Uveitis Scleritis Episcleritis Acute dry eye

18 Topical Steroids Steroids inhibit phospholipase A2: which in turn inhibits both pain & the patient s immune system They decrease inflammation by reducing the production of exudates, stabilize cell membranes, inhibit the release of lysozymes by granulocytes & suppress the circulation of lymphocytes This in turn decreases the production of pain modulators by blocking pain-mediated prostaglandin pathways.

19 Topical steroid risks Increased intraocular pressure Risk of secondary infection Risk of cataract formation (long term) Caution in corneal healing

20 Topical steroids Potency, concentration, corneal penetration & ocular contact time. acetate vs ester based Ester based: less likely to cause IOP elevation drop vs ointment

21 IOP response Ketone-based steroids more likely to cause elevated IOP than ester-based. Prednisolone Dexamethazone Durezol

22 Less likely to cause a steroid response Loteprednol etabonate (Alrex 0.2% & Lotemax 0.5%) Broken down rapidly by esterases in the body after it exerts its effect, doesn t remain in the anterior chamber and the trabecular meshwork as other steroids. This decrease contact time reduces the risk of ocular side effects

23 Topical Steroids: A role in epithelial healing Insult to cornea Leukocytes migrate from perilimbal blood vessels into anterior stroma Suppress Steroid Inflammatory cascade Non-healing epithelial defect Aids in healing

24 Topical Steroids Can generally be safely added by day 2 or 3 in corneal insult cases Commonly used topical steroids Lotemax gel/suspension (loteprednol 0.5%) For use in mild inflammatory conditions Pred Forté (prednisolone acetate 1%) Durezol (diflupednate 0.05%) Typical dosing schedule is BID to TID postoperatively Shown to be as effective at QID dosing schedule as prednisolone acetate administered eight times a day with endogenous anterior uveitis Therefore, effective used at a lower dosage schedule compared to PF.

25 Oral Pain Management Options History: Look for interactions OTC meds Allergy Pregnancy CNS considerations Kidney or liver disease Alcohol use or other pain medications Metabolism of drugs

26 Options Non-narcotics Analgesics NSAID Cox-2 inhibitor Narcotics Schedule II-V More less addictive

27 OTC options for mild to moderate pain ASA: Salicylates* Not really a good choice mg every 4 hours Contraindicated in ASA allergy, bleeding ulcers, bleeding disorders, people who drink more than 3 alcoholic beverages a day, pregnancy (category D), under 18 yo with viral infection

28 OTC options for mild to moderate pain Acetaminophen (ie. Tylenol): analgesic Multiple dosages available, starting at 325mg Every 4 hours, max 3000 mg Contraindicated in liver disease, alcoholism and acetaminophen hypersensitivity Leading cause of acute liver failure in the US Commonly paired with opioids to potentiate their effect and improve the efficacy of the opioid.

29 OTC options for mild to moderate pain Oral NSAIDS: pain + anti-inflammatory Contraindicated in ASA allergies Precaution used in active peptic ulcer or GI disease, renal or liver impairment, heart failure, edema, HTN Adverse reactions: GI ulcer/bleeding/upset, headache, dizziness, fluid retention, rash, pruritis, tinnitus Utilized in ocular surface injuries Moderate to severe episclerititis Mild scleritis Uveitis Postoperative

30 Options Cataflam (Diclofenac) 50 mg TID Initially can give 100 mg then follow with 50 mg TID Ibuprofen: NSAID (ie. Motrin) Analgesic, antipyretic and anti-inflammatory properties 200 to 800 mg every 4 hours, max 2400 mg Side effects better if max dose is 1600 mg Naproxen: NSAID (ie. Aleve) 200 mg every 12 hours, max 1500 mg Can use 2 tabs as a loading dose, with no more than 3 tabs in 24 hour period.

31 Cox 2 Inhibitors Better GI tolerance Celebrex Acute pain 400 mg initial dose, then 200 mg day 1 followed by 200 mg BID

32 Four categories of opioids: Natural opioids (including morphine and codeine) and semi-synthetic opioids (drugs like oxycodone, hydrocodone, hydromorphone, and oxymorphone) Methadone, a synthetic opioid Synthetic opioids other than methadone (drugs like tramadol and fentanyl) Heroin, an illicit (illegally made) opioid synthesized from morphine Powder of sticky black substance

Narcotics (+analgesic) Examples Tylenol III Codeine phosphate 30mg, acetaminophen 300 mg Adverse reactions: nausea, vomiting common Lortab 2.5/500, 5/500, 7.5/500, 10/500 5.

33 Narcotics (+analgesic) Examples Tylenol III Codeine phosphate 30mg, acetaminophen 300 mg Adverse reactions: nausea, vomiting common Lortab 2.5/500, 5/500, 7.5/500, 10/ mg hydrocodone bitartrate, 500 mg acetaminophen Sig: 1 or 2 tabs q 4-6 hrs as needed for pain Vicodin 5/500, ES 7.5/750, HP 10/660 Hydrocodone bitartrate and acetaminophen Vicoprofen Norco 10/325 Hydrocodone/acetaminophen. Percocet 2.5/325 or 5/325 or 7.5/500 etc. Oxycodone and acetaminophen Highest street value FDA: As of October 2014 all combination hydrocodone drugs are now Schedule II

34 Centrally acting agents Ultram 50 mg Tramadol: synthetic analogue of codeine For moderate to severe pain relief Recently moved to a controlled substance Now classified as an opioid Clinically equivalent to Tylenol #3 minimal side affects Two mechanisms of action: First it binds to the µ-opioid receptor Second it inhibits reuptake of serotonin and norepinephrine Irrespective of meals, however better tolerated with food 1 to 2 tabs q 4-6 hrs. (max of 400 mg/day) Interactions include: warfarin, digoxin, and Tegretol

35 Centrally acting agents Ultracet Opioid + acetaminophen 37.5 mg Tramadol, 325 mg of acetaminophen Indications: Short-term (5 days) management of acute pain ii tabs q 4-6 hrs

36 Adverse reactions: Dizziness, CNS and respiratory depression, GI upset, constipation, hepatotoxicity, urinary retention etc. Interactions: Alcohol, CNS depressants, MAOIs, tricyclic antidepressants, anticholinergics

Ultram/Ultracet Contraindications: Acute intoxications Hypnotics Narcotics Centrally acting analgesics Other opioids Psychotropics Precaution in opioid-dependent patients,

37 Ultram/Ultracet Contraindications: Acute intoxications Hypnotics Narcotics Centrally acting analgesics Other opioids Psychotropics Precaution in opioid-dependent patients, respiratory depression, head injury, seizure disorders etc. Adverse effects (minimal): dizziness, nausea, constipation, headache, somnolence, GI upset, dry mouth, itching, CNS stimulation

38 From the CDC 1990 s: increased opiod prescribing practices Overdose deaths involving prescription opioids were five times higher in 2016 than in Seth P, Rudd R, Noonan, R, Haegerich, T. Quantifying the Epidemic of Prescription Opioid Overdose Deaths.American Journal of Public Health, March 2018;108(4),e1-e3. In 2016: 63,632 drug overdose deaths occurred in the United States. An increase of 21.5% from 2015 Deaths from drug overdose are up among both men and women, all races, and adults of nearly all ages. More than three out of five drug overdose deaths involve an opiod. Hedegaard H, Warner M, Miniño AM. Drug overdose deaths in the United States, NCHS Data Brief, no 294. Hyattsville, MD: National Center for Health Statistics. 2017/ CDC. Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; Available at

39 The impact is not concentrated in 1 region or community, such as low social-economics. Players at fault Doctors Insurance companies Drug companies Patients Response to the epidemic Prescription drug monitoring programs PDMP Narcon Yearly cost of methadone $4700 vis $24000 for incarceration

40 The new face of drug addiction

41 Check boxes: state law in some states Consider write out # given No refills- Indiana Not valid after 6 months Beware: Drug seeking behavior!

42 I ll take mine sunny side up.

47 Picked it Culture Valtrex 500 mg TID Zirgan 5 x day Homatropine 5% TID Narco 10 BMI consideration

48 Miserable sinus infection Acylovir 800 mg 5 x day Lotemax QID Homatropine 5% BID Combigan BID Lortab

49 Herpes Simplex: cl abuse Poorly compliant extended wear CL History of HSV- IN THE OTHER EYE

51 Management Zirgan Bandage contact lens Topical Steroid Cycloplegic Atropine 1% BID Oral medication pain relief Tramadol

52 Bandage Contact Lenses Used in central or large abrasions Recommend not to use in conjunction with ointments or lubricant ointments. For large abrasions, may not remove on the first follow-up visit. Safely used in conjunction with drops Extra caution in the use with CL induced abrasions RTC hrs to check for healing

53 As a reminder, this is a chargeable fee Medicare guidelines: Specify which eye 1 x month Average: $45.00 (Natl. 2014)

54 Wrestling around Alger s brush debridement Moxeza QID Homatropine 5% in office Bandage contact lens Declined oral pain medications

55 Cases for Review

56 Don t flick your Bic. 24 yo white female CC: hit with a BIC lighter in the right eye Pain: 9/10, tearing, swollen, black and blue eye Denied flashes, floaters, curtain, veil Denies abuse at home Reports being struck by a lighter thrown across the room by a friend. Denies bleeding disorders, did take ibuprofen after incident

57 Pertinent clinical findings of affected eye CF 3 PH 20/400 Conjunctival laceration Central corneal abrasion with 2+ corneal stromal edema Hyphema Tramatic iritis Iris sphincter tears Commotio retinae IOP 18mmHg Pain management: Atropine 1% BID Tobradex QID Norco 10

63 Well after inflammation was under control and corneal defect had healed, patient requested additional pain medication. Frequent use of the local ER Know when to say no.

$Bar fight CT scan Retrobulbar hemorrhage (-) orbital fracture Elevated IOP: 44$

66 Bar fight CT scan Retrobulbar hemorrhage (-) orbital fracture Elevated IOP: 44 mmhg Combigan NSAIDS: bleeding risk Narcotic: acute alcohol intoxication Ice packs

67 Contact lens overwear with central abrasion: Bandage CL: risk of infection (cautiously) Central but small abrasion so centrally acting agents probably not necessary Pain Management: Cycloplegic agent Topical steroid once appropriate

68 That call on a Friday night.. Son was hit with a golf ball

70 IOP reported at 56mmHg Vomiting S/P ER lateral canthotomy

71 4+ Anterior chamber rxn Vitreous hemorrhage Intraretinal and retrobulbar hemorrhage Irregular pupil No obvious retinal detachment Atropine Combigan Refused narcotic Sensitive stomach Rebleed possibility Tylenol

Thickness Map Single Exam Report OU SPECTRALIS Tracking Laser

G 1n e e r1n s M OS 700 700 600,;o!P. socii 600,;o sotil "r:' :.

1 0 0 0 Center: Central Min: Central Max: 115 µm 83 µm 228 µm

340 µm Circle Diameters: 1,3,6 mm ETD Circle Diameters: 1, 3,6 mm

73 Thickness Map Single Exam Report OU SPECTRALIS Tracking Laser Tomography Patient: Patient ID: Diagnosis: OD IR 30 ART [HS) 800 DOB: Exam.: Comment: OcU28/1997 Dec/1/2017 Sex: 800 H E I C E L B E r G e n G 1n e e r1n s M OS ,;o!P. socii 600,;o sotil "r:' : q). 3 0 Q : ; 2 0 &! Center: Central Min: Central Max: 115 µm 83 µm 228 µm <"t>' Center: Central Min: Central Max: 256 µm 244 µm 340 µm Circle Diameters: 1,3,6 mm ETD Circle Diameters: 1, 3,6 mm ETDRS lnotes: Date: 't../ 11)-<-f r== = Solrware Vo1$fon: 6.S.J Signature: e l d o / 1gEngfnf1crfnfJ.c0111 T11lclmoss fa;ip Slnglo Ex;Jm Report OU

74 180 NAS Position [ ]

30 ' I 250 200.30 Hemis here As mmet Avera e Thickness m Avera e Thickness m S - 1 E'.3; Superior (S) 0... 242. c, g 20 Total 253 0"., ' c "ti 10.

75 Asymmetry Analysis Single Exam Report OU SPECTRALIS Tracking Laser Tomography Patient: Patient ID: Diagnosis: OD bu I tsu DOB: Exam.: Comment: Oct/28/1997 Dec/1/2017 OS - OD As mmet Sex: H E I O E L B E r G e n G 1ne e r 1n G M OS "[., 00 c: fsso I - "' c: "I- 450 ;o 40dḷ =r Cḷ>. 30 ' I Hemis here As mmet Avera e Thickness m Avera e Thickness m S - 1 E'.3; Superior (S) c, g 20 Total 253 0"., ' c "ti 10." ' c; c: 0 I - S Inferior (I) Superior (S) 315 Total 313 Inferior (I) 311 =- Hem1soh1ere Asvmmetrv S - I I - s Notes: [ Date: 12/1/2017 Signature: -L/ _ :r:--- --: Sofrwaro Version: f.8.j rg Engln eering.com Asymm oti y An;J/ysis Sln g/o EJcam Report OU

76 I.0 Three in One Eye: Right Name: DOB: I10:60'f t:su Central 24-2 Threshold Test Fixation Monitor: Gaze/Blind Spot Fixation Target: Central Fixation Losses: 1/22 False POS Errors: O/ 15 False NEG Errors: 0/13 Test Duration: 12:03 Fovea: 33 db Stimulus: V. White Pupil Diameter: 6.9 mm Background: 31.5 ASB Visual Acuity: Strategy: Full Threshold RX: OS DC X Threshold Graytone Date: Time: 10:03 AM Age: I I I.... I Ị Defect Depth (db} Threshold (db) (34) (33) ( ) (33) ll ll (21 9 A l l 17 ll ll (27) ll (33) 7 ( 7) 31) (31) ( 7) ( ( 277) 13 (31) 1) (31) (15) ) (33) (33) o = Within 4 db of Expected Central Reference: 38 db +. f r fbou ttwhhlr! ro'dtbs 1 ht, 1 doht'lwfh,,f n O f t r t t 'f z t : ' +=lf r " *' f f f t l t d t zf l ' Carl Zeiss Meditec HFA II /5.1.2

79 CC: Pain from glaucoma 36 year old white male Known history of glaucoma secondary to pigment dispersion Diagnosed the previous year with IOP of 32 Prostaglandin drop IOP reduction to 17mmHg Lost to follow up Came in for pain related to his glaucoma. Multiple medical clinics would not refill his pain med script until he saw his eye doctor. IOP 27mmHg (never filled the Rx)

80 Slit lamp: Pertinent negatives: no corneal defects or edema No anterior chamber reaction IOP 34mmHg DFE: consistent with glaucomatous progression Plan: Restart prostaglandin Thanks, but no thanks.

81 Always remember: what else could it be Mild to moderate ocular DES Blepharitis Conjunctivitis Ocular ischemic syndrome Periorbital Herpetic prodrome Lid/lacrimal infection Referred pain Dental Sinusitis Moderate to severe ocular Scleritis Endophthalmitis Acute angle-closure glaucoma Orbital Sinusitis Cellulitis Orbital pseudotumor Mass effect Optic neuritis Migraine/cluster headache

82 In summary Know what you are treating. Caution in masking the pain Understand the nature of the pain and the severity. Most ocular pain is short lived. Keep in mind concomitant inflammation. Make therapeutic choices based on the nature and severity of the pain.

83 Thank you.

! Somatic! Visceral! Neuropathic! Psychogenic. ! Analgesic! Relief without sedation! Works on peripheral pain receptors

PAIN, PAIN, GO AWAY. TYPES OF PAIN! Somatic! Visceral! Neuropathic! Psychogenic Jill Autry, OD, RPh Eye Center of Texas, Houston drjillautry@tropicalce.com ANALGESIA! Mild! Aspirin! Paracetamol! Moderate!