Efficacy of diclofenac versus dexamethasone for treatment after strabismus surgery

Diclofenac for acute postoperative pain in children

BACKGROUND

Many children undergo various surgeries, which often lead to acute postoperative pain. This pain influences recovery and quality of life. Non-steroidal anti-inflammatory drugs (NSAIDs), specifically cyclo-oxygenase (COX) inhibitors such as diclofenac, can be used to treat pain and reduce inflammation. There is uncertainty regarding diclofenac's benefits and harms compared to placebo or other drugs for postoperative pain.

OBJECTIVES

To assess the efficacy and safety of diclofenac (any dose) for acute postoperative pain management in children compared with placebo, other active comparators, or diclofenac administered by different routes (e.g. oral, rectal, etc.) or strategies (e.g. 'as needed' versus 'as scheduled').

SEARCH METHODS

We used standard, extensive Cochrane search methods. We searched CENTRAL, MEDLINE, and trial registries on 11 April 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in children under 18 years of age undergoing surgery that compared diclofenac (delivered in any dose and route) to placebo or any active pharmacological intervention. We included RCTs comparing different administration routes of diclofenac and different strategies.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Our primary outcomes were: pain relief (PR) reported by the child, defined as the proportion of children reporting 50% or better postoperative pain relief; pain intensity (PI) reported by the child; adverse events (AEs); and serious adverse events (SAEs). We presented results using risk ratios (RR), mean differences (MD), and standardised mean differences (SMD), with the associated confidence intervals (CI).

MAIN RESULTS

We included 32 RCTs with 2250 children. All surgeries were done using general anaesthesia. Most studies (27) included children above age three. Only two studies had an overall low risk of bias; 30 had an unclear or high risk of bias in one or several domains. Diclofenac versus placebo (three studies) None of the included studies reported on PR or PI. We are very uncertain about the benefits and harms of diclofenac versus placebo on nausea/vomiting (RR 0.83, 95% CI 0.38 to 1.80; 2 studies, 100 children) and any reported bleeding (RR 3.00, 95% CI 0.34 to 26.45; 2 studies, 100 children), both very low-certainty evidence. None of the included studies reported SAEs. Diclofenac versus opioids (seven studies) We are very uncertain if diclofenac reduces PI at 2 to 24 hours postoperatively compared to opioids (median pain intensity 0.3 (interquartile range (IQR) 0.0 to 2.5) for diclofenac versus median 0.7 (IQR 0.1 to 2.4) in the opioid group; 1 study, 50 children; very low-certainty evidence). None of the included studies reported on PR or PI for other time points. Diclofenac probably results in less nausea/vomiting compared to opioids (41.0% in opioids, 31.0% in diclofenac; RR 0.75, 95% CI 0.58 to 0.96; 7 studies, 463 participants), and probably increases any reported bleeding (5.4% in opioids, 16.5% in diclofenac; RR 3.06, 95% CI 1.31 to 7.13; 2 studies, 222 participants), both moderate-certainty evidence. None of the included studies reported SAEs. Diclofenac versus paracetamol (10 studies) None of the included studies assessed child-reported PR. Compared to paracetamol, we are very uncertain if diclofenac: reduces PI at 0 to 2 hours postoperatively (SMD -0.45, 95% CI -0.74 to -0.15; 2 studies, 180 children); reduces PI at 2 to 24 hours postoperatively (SMD -0.64, 95% CI -0.89 to -0.39; 3 studies, 300 children); reduces nausea/vomiting (RR 0.47, 95% CI 0.25 to 0.87; 5 studies, 348 children); reduces bleeding events (RR 0.57, 95% CI 0.12 to 2.62; 5 studies, 332 participants); or reduces SAEs (RR 0.50, 95% CI 0.05 to 5.22; 1 study, 60 children). The evidence certainty was very low for all outcomes. Diclofenac versus bupivacaine (five studies) None of the included studies reported on PR or PI. Compared to bupivacaine, we are very uncertain about the effect of diclofenac on nausea/vomiting (RR 1.28, 95% CI 0.58 to 2.78; 3 studies, 128 children) and SAEs (RR 4.52, 95% CI 0.23 to 88.38; 1 study, 38 children), both very low-certainty evidence. Diclofenac versus active pharmacological comparator (10 studies) We are very uncertain about the benefits and harms of diclofenac versus any other active pharmacological comparator (dexamethasone, pranoprofen, fluorometholone, oxybuprocaine, flurbiprofen, lignocaine), and for different routes and delivery of diclofenac, due to few and small studies, no reporting of key outcomes, and very low-certainty evidence for the reported outcomes. We are unable to draw any meaningful conclusions from the numerical results.

AUTHORS' CONCLUSIONS

We remain uncertain about the efficacy of diclofenac compared to placebo, active comparators, or by different routes of administration, for postoperative pain management in children. This is largely due to authors not reporting on clinically important outcomes; unclear reporting of the trials; or poor trial conduct reducing our confidence in the results. We remain uncertain about diclofenac's safety compared to placebo or active comparators, except for the comparison of diclofenac with opioids: diclofenac probably results in less nausea and vomiting compared with opioids, but more bleeding events. For healthcare providers managing postoperative pain, diclofenac is a COX inhibitor option, along with other pharmacological and non-pharmacological approaches. Healthcare providers should weigh the benefits and risks based on what is known of their respective pharmacological effects, rather than known efficacy. For surgical interventions in which bleeding or nausea and vomiting are a concern postoperatively, the risks of adverse events using opioids or diclofenac for managing pain should be considered.

Diclofenac Versus Corticosteroids Following Strabismus Surgery: Systematic Review and Meta-analysis

The purpose of the current study was to compare outcomes of diclofenac versus corticosteroids following strabismus surgery. A systematic review and meta-analysis were performed in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. An electronic search was performed to include comparative studies of diclofenac versus corticosteroids following strabismus surgery. The analysis was based on fixed and random effect models. Primary outcomes included discomfort, chemosis, inflammation, conjunctival gap, intraocular pressure, and conjunctival injection. Secondary outcomes were conjunctival congestion, discharge, and drop intolerance. Eight studies with a sample of 469 eyes were included. At weeks 1 and 4 postoperatively, there were no statistically significant differences between the diclofenac and corticosteroid groups, except for conjunctival injection at week 1 (mean difference [MD] = -0.21, P = .04) favoring diclofenac. Interestingly, all primary outcomes significantly favored diclofenac at week 2: discomfort (MD = -0.34, P = .03), conjunctival chemosis (MD = -0.16, P = .04), conjunctival inflammation (MD = -0.16, P = .02), conjunctival gap (MD = -0.17, P = .002), intraocular pressure (MD = -2.53, P < .00001), and conjunctival injection (MD = -0.30, P = .03). Moreover, conjunctival congestion was significantly improved for dexamethasone, whereas discharge and drop intolerance was not statistically different. Diclofenac is comparable to various corticosteroids when used following strabismus surgery. However, it is important to note that diclofenac yielded significant improvements in discomfort, conjunctival chemosis, inflammation, conjunctival gap, intraocular pressure, and conjunctival injection, mainly at 2 weeks postoperatively. [J Pediatr Ophthalmol Strabismus. 2023;60(5):312-322.].

Diclofenac Versus Dexamethasone Following Strabismus Surgery: A Systematic Review and Meta-Analysis

Purpose: To compare outcomes of diclofenac versus dexamethasone in patients after strabismus surgery. Methods: A systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search was conducted on MEDLINE, EMBASE, EMCARE, CINAHL, and the Cochrane Central Register of Controlled Trials (CENTRAL). All randomized controlled trials (RCTs) comparing the outcomes of diclofenac versus dexamethasone poststrabismus surgery were included. An extraction spreadsheet for data collection and Review Manager 5.3 were used for data analysis based on the fixed and random effects models. Discomfort, inflammation, chemosis, conjunctival gap, and intraocular pressure (IOP) were primary outcome measures. Secondary outcomes included conjunctival congestion and injection, discharge, and drop intolerance. Fixed and random effects models were used for the analysis. Results: Five RCTs enrolling 248 subjects were enrolled. At week 2 postoperatively, there was a significant difference favoring diclofenac over dexamethasone in terms of discomfort (mean difference [MD] = -0.37, P = 0.02), conjunctival inflammation (MD = -0.16, P = 0.02), conjunctival chemosis (MD = -0.16, P = 0.04), and postoperative conjunctival gap (MD = -0.17, P = 0.002). In terms of IOP, there were no significant differences. However, no statistically significant differences were noted at weeks 1 and 4 postoperatively. For secondary outcomes, dexamethasone had significantly improved conjunctival congestion; however, diclofenac had significantly less injection at the site of muscle attachments at week 2. No significant difference was noted in terms of discharge and drop intolerance. Conclusion: Diclofenac is comparable to dexamethasone when used following strabismus surgery. However, a significant difference favoring diclofenac in terms of discomfort, inflammation, conjunctival chemosis, and conjunctival gap was only noted at 2 weeks postoperatively. The authors suggest conducting further studies to support the effectiveness of diclofenac as an alternative to corticosteroids following strabismus surgery.

Ocular nonsteroidal inflammatory drugs: where do we stand today?

Since their first introduction in ophthalmology, the use of NSAIDs (nonsteroidal anti-inflammatory drugs) has been exponentially expanded, with numerous therapeutic applications. Despite their controversial history, they have proven their efficacy as anti-inflammatory agents in a variety of diseases. Nowadays, NSAIDs are part of surgical protocols of the most commonly performed ophthalmic operations, such as cataract or ocular surgery. They are universally implicated in the management of conjunctivitis, retinal and choroidal disease and miscellaneous inflammatory diseases. Moreover, although linked with serious adverse events and toxicities, their therapeutic magnitude in Ophthalmology should not be affected. This review systematically portrays the variety of ocular NSAIDs available to date, along with their differences in their way of action, indications and potential side effects in various ophthalmologic conditions.

Comparison of the Efficacy of Topical Chloramphenicol 0.5%-Betamethasone 0.2% (CB) and CB Associated with Sodium Hyaluronate/Trehalose/Carbomer Gel Following Strabismus Surgery

Purpose: To compare the efficacy of topical chloramphenicol 0.5%-betamethasone 0.2% (CB) and CB associated with sodium hyaluronate/trehalose/carbomer (HTC-gel) gel following strabismus surgery. Methods: Longitudinal, single-arm, study case series analysis involved patients undergoing bilateral symmetrical horizontal strabismus surgery. One eye received CB alone and the contralateral eye CB and HTC-gel. Both treatments were instilled 3 times a day for 4 weeks postoperatively. Ocular inflammation was assessed objectively at 1 and 4 weeks by Efron scale for conjunctival redness. Foreign body sensation, burning/stinging, itching, pain, stick feeling, and blurred vision were evaluated by the numerical rating scale. Results: There were 31 patients included in the study. The mean age at presentation was 51 years (standard deviation 24, range 19-85). Conjunctival inflammatory at 1 and 4 weeks showed no statistically significant difference between the 2 treatments (P = 0.75 and P = 0.33, respectively). At 1 week postsurgery, all the subjective parameters showed a significant difference (P < 0.0001) between the 2 groups of treatment to the exclusion of "itching" and "pain" (P = 0.18 and P = 0.67, respectively) with higher scores, to the exception of "blurred vision" in the CB treatment. At 4 weeks postoperatively, no statistically significant differences between the 2 groups (P > 0.16) of treatments were observed, with the exception of the symptom "blurred vision" (0.00 vs. 1.65, CB vs. CB and HTC-gel, respectively, P < 0.0001). Conclusion: CB associated with HTC-gel seems to be an effective treatment option following strabismus surgery.

The incidence and clinical outcome of complications in 4,000 consecutive strabismus operations

PURPOSE

To test the validity of the British Ophthalmic Surveillance Unit (BOSU) study's incidence figure of severe complications following strabismus surgery and to determine the incidence, type, risk factors, and outcome of all strabismus surgery complications at a single institution.

METHODS

A prospective audit of consecutive strabismus operations performed by consultants or trainees was carried out between 2011 and 2016 at Moorfields Eye Hospital NHS Foundation Trust. Patient diagnosis, age, sex, surgical details, complications, and outcome were recorded from hospital records. We classified complications as minor, moderate, or severe. The outcome was graded using the Bradbury and Taylor grading system (I to IV), with a poor or very poor outcome meaning loss of corrected visual acuity or unexpected primary position diplopia.

RESULTS

A total of 4,076 consecutive strabismus operations were performed during the study period. There were 46 (1.13%) complications, of which 28 (0.69%) were minor, 7 (0.17%) were moderate, and 9 (0.22%) were severe. Only 1 patient (0.02%) had a poor visual outcome. Two patients had nonocular postoperative complications (0.05%).

CONCLUSIONS

In this large, prospective series, we found the rate of severe complications of strabismus surgery to be 1 in 455 cases. Our results validate the findings of the BOSU study.

A randomized controlled trial comparing the efficacy of topical antibiotic steroid combination versus no treatment after fornix-incision strabismus surgery

PURPOSE

To compare comfort and inflammation in patients treated with postoperative topical antibiotic steroids in one eye versus no treatment in the other eye.

METHODS

This prospective, randomized single-masked study included all patients with planned symmetrical strabismus surgery via fornix incision. One eye was randomly assigned to topical postoperative tobramycin-dexamethasone and the other eye was not treated. Patient and parent questionnaires were administered, and two masked observers assessed conjunctival injection over the muscle and wound site.

RESULTS

A total of 70 patients completed at least 1 postoperative visit and were included. There was no statistically significant difference between the treatment eye and the no treatment eye in any of the studied parameters.

CONCLUSIONS

Postoperative topical antibiotic steroid did not prove to be superior to no treatment in uncomplicated fornix surgery with regard to patient comfort and inflammation. In those cases, consideration may be given to sparing the patient the inconvenience, cost, and potential complications of the topical medication.

Efficacy and Safety of Loteprednol 0.5% and Fluorometholone 0.1% After Strabismus Surgery in Children

PURPOSE

To compare the effects of topical loteprednol and fluorometholone in children who underwent strabismus surgery.

METHODS

This is a retrospective observational case series. A total of 60 Korean children who underwent strabismus surgery between January 2016 and September 2016 were included. Patients were prescribed topical loteprednol etabonate 0.5% or fluorometholone 0.1% until 3 weeks after surgery. Four parameters (intraocular pressure [IOP], conjunctival injection, conjunctival inflammation, and patient discomfort) were assessed every week for up to 4 weeks after surgery. Main outcome measures were comparison of parameters between the 2 groups at each following week after surgery. In addition, factors associated with clinically meaningful IOP elevation were evaluated.

RESULTS

IOP was significantly elevated at the second and third postoperative week compared with baseline (P = 0.028 and 0.001) in the loteprednol group but not significantly in the fluorometholone group. The mean IOP of the loteprednol group at 1 and 3 weeks after surgery were significantly higher than that of the fluorometholone group (P = 0.032 and 0.017, respectively). Multivariate analysis revealed that age ≤8 years (odds ratio 14.52, 95% confidence interval 1.16-139.05) was associated with IOP >21 mmHg. There was no significant difference between the 2 groups in patient discomfort, conjunctival inflammation, and conjunctival injection.

CONCLUSIONS

Loteprednol and fluorometholone showed similar anti-inflammatory effect after strabismus surgery in children. Loteprednol appeared to have more effect on IOP elevation than fluorometholone, especially in children ≤8 years of age. When treating young patients with loteprednol, clinicians should be aware of IOP elevation.

Comparison of the Safety and Efficacy of Loteprednol Etabonate 0.5%/Tobramycin 0.3% with Dexamethasone 0.1%/Tobramycin 0.3% Following Strabismus Surgery

OBJECTIVE

To compare the anti-inflammatory efficacy and safety of 0.5% loteprednol etabonate/0.3% tobramycin (LE/T) and 0.1% dexamethasone/0.3% tobramycin (DM/T) ophthalmic suspensions following strabismus surgery.

MATERIALS AND METHODS

The records of 40 patients who were treated with either LE/T or DM/T following strabismus surgery were retrospectively reviewed. The recorded signs and symptoms of inflammation and intraocular pressure of the patients at 1 day, 1 week, and 3 weeks after the surgery were evaluated and compared between the groups.

RESULTS

In both groups, reduced inflammation was noted during the follow-up visits. There was no statistically significant difference between the LE/T and DM/T groups with regard to the postoperative scores or measurements, including discomfort, chemosis, secretion, conjunctival hyperemia, and conjunctival gap size (p>0.05), during the follow-up visits. Allergic reactions to the medications were not reported in any patient. Intraocular pressures were within normal limits in both groups.

CONCLUSION

LE/T was found to be as effective as DM/T in reducing inflammation after strabismus surgery. LE/T, as a new-generation steroid combination product, could be used as a safe and effective anti-inflammatory agent for the treatment of inflammation following strabismus surgery.

Antinociceptive synergy between diclofenac and morphine after local injection into the inflamed site

BACKGROUND

Combinations of non-steroidal anti-inflammatory drugs with opioids are frequently used to reduce opioid doses required in the clinical management of acute pain. The present study was designed to evaluate the possible antinociceptive interaction between morphine and diclofenac at peripheral level in male rats.

METHODS

Drugs were chosen based on their efficacy in the treatment of this kind of pain and as representative drugs of their respective analgesic groups. For the formalin test, 50 μ of 1% formalin solution was injected subcutaneously into the right hind paw. The interaction between morphine and diclofenac was evaluated by using isobolographic analysis and interaction index. Drug interaction was examined by administering fixed-ratio combinations of morphine-diclofenac (1 : 1 and 3 : 1) of their respective ED30 fractions.

RESULTS

Diclofenac and morphine reduced flinching behavior in a dose-dependent manner during phase 2 but not phase 1 of the formalin test. Isobolographic analysis showed a synergistic interaction for the combination of morphine and diclofenac after local peripheral administration.

CONCLUSIONS

Data suggest that the combination of morphine with diclofenac at the site of injury is synergistic and could be useful in the treatment of wounds, bruises, rheumatisms and other painful peripheral conditions associated with an inflammatory process.

The role of anti-inflammatory agents in age-related macular degeneration (AMD) treatment

Although age-related macular degeneration (AMD) is not a classic inflammatory disease like uveitis, inflammation has been found to have an important role in disease pathogenesis and progression. Innate immunity and autoimmune components, such as complement factors, chemokines, cytokines, macrophages, and ocular microglia, are believed to be heavily involved in AMD development. Targeting these specific inflammatory molecules has recently been explored in an attempt to better understand and treat AMD. Although antivascular endothelial growth factor therapy is the first line of defence against neovascular AMD, anti-inflammatory agents such as corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), immunosuppressive agents (eg, methotrexate and rapamycin), and biologics (eg, infliximab, daclizumab, and complement inhibitors) may provide an adjunct or alternative mechanism to suppress the inflammatory processes driving AMD progression. Further investigation is required to evaluate the long-term safety and efficacy of these drugs for both neovascular and non-neovascular AMD.

Nonsteroidal anti-inflammatory drugs in ophthalmology

Nonsteroidal anti-inflammatory drugs (NSAIDs) are increasingly employed in ophthalmology to reduce miosis and inflammation, manage scleritis, and prevent and treat cystoid macular edema associated with cataract surgery. In addition, they may decrease postoperative pain and photophobia associated with refractive surgery and may reduce the itching associated with allergic conjunctivitis. In recent years, the U.S. Food and Drug Administration has approved new topical NSAIDs, and previously approved NSAIDs have been reformulated. These additions and changes result in different pharmacokinetics and dosing intervals, which may offer therapeutic advantages. For example, therapeutic effects on diabetic retinopathy and age-related macular degeneration may now be achievable. We provide an updated review on NSAIDs and a summary of their current uses in ophthalmology with attention to potential future applications.

Topical pranoprofen 0.1% is as effective anti-inflammatory and analgesic agent as diclofenac sodium 0.1% after strabismus surgery

To compare the anti-inflammatory and analgesic effects of topical pranoprofen 0.1% with diclofenac sodium 0.1% after strabismus surgery, 40 patients were prospectively randomized and assigned into 2 groups. Signs and symptoms of inflammation, as well as intraocular pressure (IOP) of patients, were evaluated at 1 day and 1 and 3 weeks following surgery. Both groups reported reduced inflammation and discomfort at 1 week, as compared to 1 day. There was no statistically significant difference in any measurement of postoperative inflammation (i.e., discomfort, chemosis, secretion, conjunctival hyperemia, and conjunctival gap size) between the 2 groups at any time. None of the patients developed an allergic reaction to the medications and IOP measurements were within the normal limits in both groups. Pranoprofen 0.1% was found to be as effective as diclofenac sodium 0.1% in reducing inflammation and pain after strabismus surgery. Pranoprofen could be used as a safe and effective anti-inflammatory alternative for the treatment of inflammation following strabismus surgery.

Ocular hypertensive and anti-inflammatory responses to different dosages of topical dexamethasone in children: a randomized trial

BACKGROUND

The purpose of the present study was to investigate the ocular hypertensive and anti-inflammatory responses to two different dosage schedules of 0.1% topical dexamethasone in a population of Chinese children undergoing strabismus surgery.

METHODS

Children undergoing bilateral strabismus surgeries were randomly assigned to receive topical 0.1% dexamethasone eye drops four times daily (group A) or twice daily (group B) for 4 weeks. Intraocular pressure (IOP) and anti-inflammatory responses were monitored for 8 weeks.

RESULTS

A total of 137 children with mean age 6.5 years (SD, 1.9 years; range, 3-10 years) participated in the study. The IOP increased significantly after 4 weeks in both groups compared to the preoperative values (P < 0.001). Peak IOP ranged from 14.0 to 50.3 mmHg in group A and 11.0-41.3 mmHg in group B. Cases in group A (mean, 13.8 mmHg; SD, 8.4 mmHg) had a greater net increase in IOP than cases in group B (mean, 10.2 mmHg; SD, 6.2 mmHg; P = 0.004). Younger-aged children had higher peak IOP (r = -0.244, P = 0.048), and attained the peak IOP earlier (r = 0.252, P = 0.041) in group A. There was no significant difference in ocular inflammatory response between the two groups.

CONCLUSION

Ocular hypertensive effect to topical 0.1% dexamethasone is dose and age dependent in children. Twice-daily 0.1% topical dexamethasone eye drops control inflammation after strabismus surgery as effectively as four-times-daily dosage, but induces less increase in IOP, and may be a better treatment schedule.

Intérêt d’une nouvelle formulation de diclofénac sans conservateur pour la surface oculaire

AIM

To compare the ocular tolerance of nonpreserved diclofenac versus thiomersal-preserved diclofenac in healthy volunteers.

MATERIALS AND METHODS

Forty healthy volunteers instilled Dicloabak in the randomised eye and thiomersal-preserved diclofenac in the other eye, according to a strictly identical dosing regimen, for 28 days. Each volunteer thus served as his or her own control. The dose regimen was five drops/day for 7 days followed by three drops/day for 20 days. Ocular tolerance was assessed by the discomfort upon instillation (measured on a visual analogue scale [VAS]), subjective ocular symptoms following instillation (irritation/burning/stinging, eye dryness and foreign body sensation) and finally by an objective examination of the ocular surface. These criteria were evaluated on days 0, 14, 21 and 28.

RESULTS

The subjective ocular symptoms following instillation were significantly lower in the nonpreserved group at Day 7 and nearly significantly lower until the end of the study. The biomicroscopy exam confirmed that there was better tolerance without thiomersal. There was less follicular-papillary conjunctivitis and a significantly better lissamine green score in the Dicloabak group.

CONCLUSION

The results of this study demonstrate that the nonpreserved formulation of diclofenac is better tolerated by the ocular surface and thus constitutes a therapeutic benefit.

Nonsteroidal anti-inflammatory drugs for postoperative pain: a focus on children

Pain is a common symptom after surgery in children, and the need for effective pain management is obvious. For example, after myringotomy, despite the brief nature of the procedure, at least one-half of children have significant pain. After more extended surgery, such as tonsillectomy, almost all children have considerable pain longer than 7 days. Nonsteroidal anti-inflammatory drugs (NSAIDs) are useful for postoperative pain management because surgery causes both pain and inflammation. Several pediatric studies indicate NSAIDs are effective analgesics in the management of mild and moderate pain. In the treatment of severe pain, NSAIDs should be given with acetaminophen (paracetamol) or opioids, and the use of an appropriate regional analgesic technique should be considered. NSAIDs are more effective in preventing pain than in the relief of established pain. Pain following surgery is best managed by providing medication on a regular basis, preventing the pain from recurring. This proactive approach should be implemented for any procedure where postoperative pain is the likely outcome. In children, the choice of formulation can be more important than the choice of drug. Intravenous administration is preferred for children with an intravenous line in place; thereafter mixtures and small tablets are feasible options. Children dislike suppositories, and intramuscular administration should not be used in nonsedated children. Ibuprofen, diclofenac, ketoprofen and ketorolac are the most extensively evaluated NSAIDs in children. Only a few trials have compared different NSAIDs, but no major differences in the analgesic action are expected when appropriate doses of each drug are used. Whether NSAIDs differ in the incidence and severity of adverse effects is open to discussion. Because NSAIDs prevent platelet aggregation they may increase bleeding. A few studies indicate that ketorolac may increase bleeding more so than other NSAIDs, but the evidence is conflicting. Severe adverse effects of NSAIDs in children are very rare, but it is important to know about adverse effects in order to recognize and treat them when they do occur. NSAIDs are contraindicated in patients in whom sensitivity reactions are precipitated by aspirin (acetylsalicylic acid) or other NSAIDs. They should be used with caution in children with liver dysfunction, impaired renal function, hypovolemia or hypotension, coagulation disorders, thrombocytopenia, or active bleeding from any cause. In contrast, it seems that most children with mild asthma may use NSAIDs.

Corticosteroid-induced glaucoma in a child after a scleral reinforcement procedure

Corticoteroid-induced glaucoma can result from either topical or systemic corticosteroid use. Compared with adults, the corticosteroid response in children is less well known. The case is reported of a child who developed glaucoma after receiving topical corticosteroids following a scleral reinforcement procedure. The raised intraocular pressure was controlled after cessation of the corticosteroids and with the use of antiglaucoma therapy. As many forms of cortico-steroids are widely used, children on corticosteroids should have regular intraocular pressure measurements as part of their management.

Comparative evaluation of diclofenac and dexamethasone following strabismus surgery

PURPOSE

To compare efficacy of topical diclofenac sodium 0.1% with dexamethasone 0.1% following strabismus surgery.

METHODS

In this study, 58 patients undergoing strabismus surgery were evaluated. They were randomized into two groups: 29 patients received topical 0.1% diclofenac (Group A), and 29 patients received 0.1% dexamethasone (Group B) for 4 weeks. The baseline parameters were similar in both groups. At each visit comprehensive ocular examination was performed to record patient discomfort, conjunctival inflammation, gap, and intraocular pressure. Follow-up visits were at 1 week, 2 weeks, and 4 weeks, postoperatively.

RESULTS

There was no statistically significant difference in the rate of resolution of the inflammation, conjunctival healing, and intraocular pressure except rise of intraocular pressure at the fourth postoperative week in group B (P value <0.001).

CONCLUSIONS

The results of this study suggest that diclofenac may be used as an alternative to dexamethasone after strabismus surgery.