Topical Ketolorac is Effective and Safe for Post- Vitrectomy Surgery Treatment

Research Article

Austin J Clin Ophthalmol. 2019; 6(1): 1100.

Topical Ketolorac is Effective and Safe for Post- Vitrectomy Surgery Treatment

Ching J1,3, Iqbal T² and Saidkasimova S¹*

¹Department of Ophthalmology, Norfolk and Norwich University Hospital, Norwich, UK

²Norwich Medical School, University of East Anglia, Norwich, UK

³John Van Geest Centre for Brain Repair, E.D. Adrian Building, Cambridge, CB2 0PY, UK

*Corresponding author: Shohista Saidkasimova, Department of Ophthalmology, Norfolk and Norwich University Hospital, Norwich, NR4 7UJ, UK

Received: December 05, 2018; Accepted: January 23, 2019; Published: January 30, 2019


Purpose: The aim of this study was to assess the efficacy of the nonsteroidal topical drug monotherapy on post-vitrectomy clinical recovery.

Methods: Retrospective analysis of case notes and post-operative Optical Coherence Tomography (OCT) of 128 eye of 128 consecutive patients undergoing primary vitrectomy for primary rhegmatogenous retinal detachment (RRD) [n = 72], full thickness macular hole (MH) [n = 42], and epi-retinal membrane (ERM) [n = 15] at a single tertiary centre between 2011 and 2015.

Results: Average LogMAR best-corrected visual acuity improved from 1.04 at baseline to 0.68 (95% CI 0.14 to -0.54, p = 0.001) at 20 weeks follow up for all indications. Average IOP did not change at follow up. Central retinal thickness (CRT) on OCT assessment did not change significantly in RRD patients postoperatively but reduced significantly in patients with MH from 389.81μm at baseline to 295.85μm at 20 weeks follow up compared to baseline (p< 0.0001). Patients with ERM had a significant reduction in CRT from 476.71μm at baseline to 388.86μm at 12 weeks (p < 0.05).

Post-operative CMO was detectable on OCT in 3 of 72 patients with RRD, 1 of 43 patients with MH and 2 of 15 patients with ERM. Overall, 6 (4.7%) patients were found to have post-operative CMO. There were few complications including 6 (4.0%) patients with persistent post-operative CMO requiring treatment beyond 20 weeks follow-up.

Conclusion: Topical ketorolac alone is an effective and safe post-operative therapy following vitrectomy surgery.

Keywords: Topical ketolorac; Vitrectomy; Post-operative; Topical steroids


A combination or single therapy of either topical steroid and/ or non-steroidal anti-inflammatory drug (NSAID) has become the typical post-operative paradigm for intraocular surgery, following the elucidation of underlying inflammatory mechanisms [1-3]. It is well known that topical corticosteroids are associated with numerous side-effects including raised intraocular pressure (IOP), development of cataract and impaired corneal epithelial healing [4,5]. The efficacy of topical NSAID monotherapy, including ketolorac, for the treatment of cystoid macular oedema following cataract surgery has been established in a meta-analysis and randomized controlled trials in the past [3,6]. A more recent meta-analysis advocates NSAID over steroid as standard treatment for pseudophakic macular oedema [7]. The role of sole use these agents following vitrectomy surgery, however, is not as clear due to the paucity of large prospective studies on use of anti-inflammatory topical medication.

The efficacy of topical NSAIDs in combination with steroids following vitrectomy has been investigated recently in randomized controlled trials for nepafenac and ketolorac versus placebo [8,9]. These studies have shown that topical NSAIDs reduce post operative pain and improve post-operative inflammation. However, nepafenac was not shown to improve visual acuity, whereas ketolorac use was associated with statistically significant improvements in visual acuity. Neither agent demonstrated any reduction in post-operative cystoid macular oedema compared to placebo when utilizing central macular thickness from optical coherence data. Importantly, both studies included topical prednisolone in both arms of each study and therefore do not demonstrate the effect of topical NSAID monotherapy.

A recent randomised trial including 80 eyes comparing topical nepafenac and prednisolone post-vitrectomy demonstrated no significant difference in visual outcomes, tolerability or inflammatory signs [10]. This study did not include an analysis of intraocular pressure, optical coherence findings and was confounded by giving patients in both treatment arms oral diclofenac sodium 50mg twice a day for 5 days, therefore limiting wider clinical application.

Herein, we perform a retrospective analysis on a series of patients treated with topical ketolorac alone following vitrectomy surgery. We demonstrate for the first time that ketolorac monotherapy is well tolerated and safe without the need for additional anti-inflammatory agents.


Retrospective analysis of case notes and post-operative Optical Coherence Tomography (OCT) scans of 128 eyes of 128 consecutive patients undergoing vitrectomy for primary rhegmatogenous retinal detachment (RRD) [n=72], full thickness macular hole (MH) (n=42], and epi-retinal membrane (ERM) [n=14] at a single tertiary centre between December 2011 and June 2015. All patients provided valid consent to proceed with surgery and this study was registered with the local Audit Department.

Patients with previous vitrectomy surgery, oil tamponade, combined phacovitrectomy, diabetes, and combined vitrectomy with scleral buckle were excluded. All patients underwent 23 gauge three port pars plana vitrectomy under local anaesthesia as a day case. Internal limiting membranes and epiretinal membranes were stained with Dual blue dye, DORG, prior to peeling. All patients were given subconjunctival injection of 0.5ml dexamethasone at the end of vitrectomy procedure. Postoperatively they were treated with a course of topical ketolorac tromethamine 0.5% ophthalmic solution (Allergan, Dublin, Ireland) four times a day for one month to the affected eye and topical chloramphenicol four times a day for one week.

Patients were reviewed at 2 weeks, 8 weeks and 20 weeks postoperatively. Day one review was not routinely conducted. At each visit postoperative best-corrected visual acuities (BCVA), Intraocular pressure (IOP), patient’s comfort, and optical coherence tomography (OCT) image data was collected. The presence of CMO was determined on clinical appearance of the OCT of each patient and not using the central retinal thickness of controls to identify its presence as previously utilised by other authors [9,11].

Continuous variables expressed as mean ± standard deviation. Categorical variables expressed as percentages. LogMAR values expressed in decimal form were converted from Snellen Acuity. The paired and independent t-test was used to analyse differences between related and independent continuous variables, respectively. Correlation was measured using Pearson’s method.

Statistical significance was considered a p value of <0.05. Analysis was performed using GraphPad Prism 7, GraphPad Software Inc., California, for Mac.


128 patients treated between December 2011 and June 2015 met the inclusion criteria utilizing the local software package Medisoft, UK, database search filters. Baseline characteristics of our study group are summarized in Table 1. Average LogMAR BCVA for all indications improved from 1.04 at baseline to 0.68 (95% CI 0.14 to -0.54, p = 0.001) at 20 weeks follow up for all indications (Figure 1). Patients treated for RRD and MH demonstrated significant improvements in BCVA, however there were no significant changes for patients with ERM (Figure 2. a-c).