We’ve seen a few articles recently discussing the potential utility of topical anesthetics for analgesia for corneal abrasions. The general point: there’s no consistent, modern evidence of harm, so why should we cling to older ways?
Counterpoint from the corneal specialist community: cling to old ways.
In this long correspondence, the authors detail the physiologic basis for their opposition to topical anesthetics as it relates to stimulation of endothelial growth. They follow this up with a three question survey regarding the practice, distributed to “an international community of cornea trained specialists”.
The clear winner in each of their three questions: “strongly disagree” with provision of topical anesthetics for acute corneal abrasions.
Interestingly, they also conflate these results with lack of justification for a clinical trial to further explore the safety and efficacy of such use:
“Often when there is a difference in clinical practice or clinical equipoise, there is an opportunity for a clinical trial. However, it is our hypothesis that within the ophthalmology community, there is not equipoise with respect to our practice of not prescribing topical anesthetics after traumatic corneal abrasions.”
I think it’s clear these specialists are making valid points regarding the potential for topical anesthetic abuse, but their citations hardly support their practice stance. I do agree, at least, regarding the lack of utility of clinical trials – but not because their use is so dangerous it cannot be tested. Rather, any clinical trial simply would be of low value as adverse events would be so rare it would be unlikely to reliably detect a difference between management strategies. It is clear topical anesthetic use will not be safe in all clinical situations, but it is rather more appropriate to provide guidance on the proper use of topic anesthetics than to simply ban them completely while continuing to cite the same anachronistic, limited evidence.
“Cornea Specialists Do Not Recommend Routine Usage of Topical Anesthetics for Corneal Abrasions”
https://www.ncbi.nlm.nih.gov/pubmed/31445551
As someone who sees patients for follow up for corneal abrasions as well as someone who has followed patients who have had corneal melts from topical anesthetic abuse and then subsequent scarring, I want to emphasize that the risk of vision loss and permanent scarring make topical anesthetic a medication that should not ever be sent home with a patient.
I absolutely agree that it can alleviate significant discomfort. In someone with a small abrasion, a topical anesthetic may not be necessary. These patients may have mild photophobia and redness but symptoms improve in days. I have found that patients with the larger abrasions are the ones who end up getting prescribed these topical drops, and unfortunately, that is the exact type of patient who shouldn’t be using it. Even with proper education, a patient may discount the side effects/proper usage of this medication, because their eye hurts, or simply because it is “just” a drop, and then delay follow up care to an ophthalmologist while an underlying infection or melt is continuing. Then when the patient decides to follow up with an ophthalmologist because the redness continues or the topical anesthetic has run out, then significant damage has already occurred.
I absolutely respect your opinion on the matter. Certainly, for many years, we just gave opiates to those with severe pain and corneal abrasions. Now, of course, opiate prescribing is increasingly under the microscope. I agree the harm is in those who abuse the drops – we probably need something like 24-48 limited supplies to prevent those whose symptoms persist from delaying follow-up, while still providing some alternative to systemic analgesia.
Topical NSAIDS – such as Prolensa – can be quite helpful for patients with corneal abrasions. Topical NSAIDS are less likely to be overused. The main issue is not the placement of a few drops of topical anesthetic – but the occasional patient that overuses topical anesthetics