Topical Anesthetic Abuse Research Articles

Preservative-Free Topical Anesthetic Unit-Dose Eye Drops for the Management of Postoperative Pain Following Photorefractive Keratectomy.

Ocular pain is a common complication following photorefractive keratectomy (PRK). The level of patient satisfaction with current pain control strategies is not high. This study aims to assess the efficacy and safety of a novel regimen of preservative-free oxybuprocaine hydrochloride 0.4% unit-dose eye drops for post-PRK pain control. In a contralateral eye study, 144 eyes of 72 patients who underwent bilateral transepithelial PRK (TransPRK) were stratified into experimental and control groups. The experimental group received preservative-free oxybuprocaine hydrochloride 0.4% unit-dose eye drops five times daily postoperatively until complete epithelial healing, while the control group received sodium hyaluronate 0.2% instead. The main outcome measures were pain scores assessed by the verbal rating scale and visual analogue scale (VRS, VAS), the corneal epithelial defect (CED) area, epithelial healing duration evaluated by slit-lamp biomicroscopy and anterior segment optical coherence tomography (AS-OCT), and endothelial cell density (ECD) measured before and 1 month after surgery. Pain scores assessed by VRS and VAS were significantly lower in the experimental group 8h after surgery, and 1, 2, and 3days postoperatively (P < 0.001). The mean CED area showed no significant differences between the two groups at different follow-ups (P value > 0.05). The corneal epithelial healing had a mean duration of 3.32 ± 0.47 days in both studied groups and was parallel in both eyes of each patient. In each group, 49 eyes (68%) and 72 eyes (100%) had a fully epithelialized surface on the third and fourth postoperative days, respectively. No significant changes were observed in the mean ECD 1 month following surgery in both groups (P value > 0.05). Preservative-free oxybuprocaine hydrochloride 0.4% unit-dose eye drops are effective and safe in controlling early postoperative pain following TransPRK. The availability of the single-dose unit preparation can overcome the problem of topical anesthetic abuse. ClinicalTrials.gov Identifier: NCT05733741.

Tropical paradise turns into a nightmare. A rare case of evisceration caused by the misuse of over-the-counter proparacaine and dexamethasone eye drops

The abuse of topical anesthetics and steroids is not uncommon. However, having an eye eviscerated is rare due to complications from abusing both topical eyedrops. We report a case of Left Eye (LE) severe corneal ulcer with panophthalmitis secondary to over-the-counter topical proparacaine and topical dexamethasone abuse

No Pain, No Gain – Topical Anesthesia-Induced Keratopathy

Topical anesthesia is an indispensable element of modern ophthalmic practice, most valuable during minor procedures and ocular examinations. However, regularly applied and prolonged use of local anesthetics may cause significant ocular damage. The spectrum of adverse effects is heterogeneous, ranging from mild conjunctival injection with superficial punctate keratopathy to persistent corneal epithelial defects, endothelial decompensation, ulcer formation, secondary infectious keratitis, and possible corneal perforation [1], [2]. Hence, timely identification of the underlying cause is essential to initiate targeted therapeutic measures. However, as topical anesthesia-induced keratopathy is a rare entity in Switzerland and its clinical picture may resemble infectious keratitis [3], the ophthalmologistʼs initial diagnosis poses a challenging task. This case report aims to further raise awareness about topical anesthetic abuse keratopathy.

Topical anesthetic abuse keratopathy in a contact lens wearer

Topical anesthetic abuse keratopathy in a contact lens wearer

Topical Ocular Anesthetic Use among Welders of Rawalpindi City, Pakistan.

A descriptive cross-sectional survey was done from January to June 2018 in welding shops of Rawalpindi city, Pakistan. The objectives of the study were to determine the frequency of topical ocular anesthetic use among welders and to assess the knowledge and practices of welders regarding safety measures. One hundred and fifty-eight welders from age group of 20 years and above, having welding work experience of more than one year, were included in the study. The sampling strategy was non-random convenient sampling. A pretested structured questionnaire was used to collect data. Topical ocular anesthetic use among welders was found to be 45.6%. Statistically significant association was found between knowledge and practices of welders regarding their safety measures (p<0.05). On binary logistic regression, work experience was found to be the strongest predictor of good knowledge (OR = 4.15, 95% CI = 1.45 - 12.15) and practices (OR=10.46 95% CI = 2.92 - 37.51). Key Words: Welder, Topical anesthetic abuse, Knowledge, Practices, Perceptions.

A rare case of infectious crystalline keratopathy caused by Burkholderia cepacia

We report a unique case of infectious crystalline keratopathy (ICK) caused by Burkholderia cepacia in a 47-year-old patient with history of multiple penetrating keratoplasties (PKPs). Slit-lamp examination revealed a white nonsuppurative needle-like branching anterior stromal infiltrate. Microscopic examination of the Gram-stained smear showed gram-negative bacilli. Cultures revealed Burkholderia cepacia, which was multidrug resistant and sensitive to piperacillin/tazobactam. Based on antibiotic sensitivity report, patient was started fortified piperacillin-tazobactam (0.32%) eye drop on an hourly basis. After 8 weeks of aggressive therapy, the infiltrate resolved with subsequent corneal scarring and vascularization. To our knowledge, this is the first reported case of Burkholderia-related ICK. ICK, first described by Gorovoy et al.[1] in 1983, is an indolent keratitis with characteristic needle-like branching opacities in the absence of corneal or anterior segment inflammation.[2] The presence of an immunocompromised corneal state, such as chronic topical steroid use post PKP, is a known risk factor for the development of ICK. Other risk factors include surgical procedures such as lamellar keratoplasty, corneal cross-linking, laser-assisted in situ keratomileusis, pterygium excision, and trabeculectomy with 5- FU. Topical anaesthetic abuse as a risk factor has also been described.[3] Burkholderia is a group of Gram-negative bacteria, composed of at least 20 different species. We describe a case of Burkholderia keratitis presenting as ICK in a patient who underwent multiple PKPs and a history of long-term topical steroid therapy.

The Misuse and Abuse of Ophthalmic Preparations: a Scoping Review of Clinical Case Presentations and Extant Literature

The emergent trend of misuse and abuse of ophthalmic drugs is a public health concern. Common ophthalmic preparations contain anticholinergics, antihistamines, decongestants, anesthetics, and vasoconstrictive and topically applied nonsteroidal anti-inflammatory drugs. Misuse and abuse relates to their effect in causing euphoria, relaxation, hallucination, and reduction of depression symptoms. A scoping review of literature was conducted using Arskey and O’Malley (International Journal of Social Research Methodology 8(1):9–32, 2005) framework for mapping extant literature on the current knowledge of the issue. Four themes emerged: abuse of cycloplegics and mydriatics, misuse and abuse of topical ophthalmic anesthetics, misuse of topical ophthalmic vasoconstrictive and topically applied nonsteroidal anti-inflammatory drugs (NSAIDs), and public and pharmacist views on ophthalmic drug abuse/misuse. The review underscores the complex motives for misuse and abuse, availability of ophthalmic products, self-medication practices, presence of co-morbidities, and low public awareness which harms the important role of health professionals regarding suspected misuse of these common products.

Keratopathy due to ophthalmic drug abuse with corneal melting and perforation presenting as Mooren-like ulcer: A case report

The present report describes the clinical course and treatment of a Mooren-like ulcer associated with abuse of topical anesthetics and dexamethasone. A 38-year-old male physician treated himself with lidocaine, tetracaine and dexamethasone (DEX) eye drops for severe pain and decline of vision in both eyes. After six months of treatment, his right cornea exhibited annular melting with full-thickness stromal infiltration at the limbus and central corneal haze. His left cornea was completely melted and exhibited iris prolapse. The patient was treated with topical antibiotics, lubricants and underwent a binocular keratoplasty. The surgery was successful and after eight months the postoperative best-corrected visual acuities were counting fingers in the right eye and light perception in the left eye. In summary, this report documents a severe case of keratopathy presenting as Mooren-like ulcer caused by topical anesthetics and DEX, which were treated via keratoplasty, resulting in useful vision being retained.

Toxic keratopathy associated with abuse of topical anesthetics and amniotic membrane transplantation for treatment.

To evaluate the clinical findings of toxic keratopathy associated with abuse of topical anesthetics and the treatment efficacy of amniotic membrane transplantation (AMT). Fifteen eyes of 10 patients with abuse of topical anesthetics were included in this study. The data collected included patients' demographic information, initial best corrected visual acuity (BCVA), clinical findings, time to AMT, duration of epithelization, additional treatments, posttreatment BCVA, and the results of psychiatric examination. All patients were male, with the mean age of 37.9±5.4y. The patients had received 0.5% proparacaine hydrochloride due to pain resulting from foreign bodies, such as welding flash burns and car battery explosions, for a mean of 18.2±12.4d. The mean initial BCVA of the patients was 0.069±0.100. All patients had persistent epithelial defects, stromal infiltration, ring ulcer, and corneal edema. Initially, medical treatment was attempted in all cases. Because of severe pain, persistent epithelial defects and progressing stromal thinning did not improve with medical treatment, thus, the patients underwent AMT. The mean posttreatment BCVA of the patients was 0.33±0.27. All of them, except for two patients, showed improved visual acuity. One patient underwent evisceration for corneal melting and endophthalmitis in another center, and one patient underwent evisceration for severe pain of unknown origin. All 5 patients who consented to a psychiatric examination had depression, had personality disorder, and used tobacco. AMT appears to be an effective method for pain relief, rapid epithelial and stromal healing; however, visual prognosis is still poor despite medical and surgical interventions.

In Vivo Confocal Microscopic Findings in the Corneas of Patients with Topical Anesthetic Abuse Keratopathy

In Vivo Confocal Microscopic Findings in the Corneas of Patients with Topical Anesthetic Abuse Keratopathy

Topical Anesthetic Abuse Keratopathy and its Clinical Progression

Sum mary To report a case series with topical anesthetic abuse and to define the clinical progression of the disease. Six eyes of three topical anesthetic abuser patients with various corneal abnormalities are reviewed. Signs of the disease are presented in order to document the natural progression of the disease. A report was filed to the General Directorate of Pharmaceuticals and Pharmacy, Ministry of Health, Ankara, Turkey describing the outcome of uncontrolled use of topical anesthetic. Topical anesthetic abuse can result in serious corneal complications such as corneal epithelium defect, ring keratitis, stromal infiltrate, hypopyon, superficial and deep corneal vascularization, corneal lysis, and at last spontaneous perforation. The General Directorate of Pharmaceuticals and Pharmacy issued that topical anesthetics can only be prescribed by an ophthalmologist up to four boxes a month, the prescription must be kept for one, year and criminal action will be taken against pharmacies disregarding these provisions. (Turk J Ophthalmol 2013; 43: 289-93)

A Comparison of the Efficacy of Autologous Serum Eye Drops with Amniotic Membrane Transplantation in Neurotrophic Keratitis

Purpose: To investigate and compare the efficacy of autologous serum eye drops with amniotic membrane transplantation in eyes with neurotrophic corneal ulcers. Methods: In this retrospective study, 42 eyes of 42 patients (30 females and 12 males) with neurotrophic corneal ulcers were included and divided into group I (n = 20) who were treated with autologous serum eye drops and group II (n = 22) who underwent amniotic membrane transplantation. The epithelial healing time and best corrected visual acuity were performed before and after treatments. Results: In group I, the mean age was 57.1 ± 10.1 years; and at the end of 6.7 ± 2.05 months follow up, 14 (70%) of 20 eyes healed completely with a minimal scarring and vascularization. Two patients had persistent epithelial defects, four patients healed incomplete because of deep stromal ulcers in eyes with post-herpes neurotrophic ulcers. In group II, the mean age was 58.7 ± 14.7 years. Seventeen eyes (72.7%) of 22 patients healed completely and there was no recurrence in these patients at the 6.8 ± 3.9 months follow-up period. Two incomplete healed patients had persistent epithelial defects caused by HSV and the other three patients had deep stromal ulcers caused by the abuse of topical anesthetics. The mean epithelialization time was 22.1 ± 8.0 days in group I and 20.0 ± 4.64 days in group II. In group I, best corrected visual acuity improved in 18 of 20 (90%) eyes and 17 of 22 (77.2%) eyes in group II. Conclusions: Both autologous serum eye drops and amniotic membrane transplantation are effective for eyes with neurotrophic corneal ulcers because of many epitheliotrophic factors. Also, we observed that multilayered amniotic membrane transplantation is more effective than autologous serum in deep corneal ulcers with postherpes neurotrophic keratitis in our cases.

Early amniotic membrane transplantation for toxic keratopathy secondary to topical proparacaine abuse: a report of seven cases

Purpose: The aim of this study is to evaluate the effect of early amniotic membrane transplantation (AMT) in patients with topical proparacaine-related toxic keratopathy.Materials and methods: Between 2008 and 2011, eight eyes of seven patients with toxic keratopathy related to 0.5% proparacaine abuse underwent early AMT (within 1 to 5 days following the diagnosis). Clinical findings and treatment outcomes of these cases were evaluated retrospectively.Results: The median time of topical anesthetic abuse until admission to our clinic was 28 (10–112) days. One case was referred due to achanthamoeba keratitis; two cases due to intractable corneal ulcer and melting. At initial examination, visual acuities varied between hand motions and 0.4 (in decimal notation). Biomicroscopic evaluation at presentation revealed epithelial defects, corneal ulcers, stromal ring infiltrate, stromal edema and corneal melting with varying degrees. At third month after AMT, the visual acuities varied between hand motions and 0.9, and all the patients had corneal stromal opacities with varying densities. One patient, who did not respond to medical and surgical treatment and developed secondary infections that invaded intraocular structures, underwent evisceration.Conclusion: Topical anesthetic abuse can lead to serious ocular complications. After proper diagnosis, the first step of treatment is the cessation of drug abuse. In addition to medical treatment, early AMT has an advantage of early pain relief and consequential elimination of the need for topical anesthetic instillation.

Topical ocular anesthetic abuse among Iranian welders: Time for action

Purpose:The purpose of this study is to estimate the prevalence of topical ocular anesthetic abuse among welders in Iran and suggest public health solutions for this issue.Methods:In this cross-sectional study, 390 welders were randomly recruited and queried on the use of anesthetic drops. A questionnaire was administered through structured one-on-one interviews conducted by the first author.Results:A total of 314 welders (80.5%) declared that they had used topical anesthetics at least once during their working lives. Almost 90% of them stated a preference for self-treatment over seeking help from a physician due to cultural and financial reasons. The most commonly used topical anesthetic was tetracaine. Most of the subjects (97.4%) had obtained the drugs from pharmacies without a prescription.Conclusions:The prevalence of topical ocular anesthetic abuse among welders in Iran is alarmingly high and may partially be due to cultural issues. Although most physicians are aware that topical anesthetics should only be used as a diagnostic tool, there is a crucial need to re-emphasize the ocular risks associated with chronic use of these medications. Educational programs for both physicians and the public are necessary to address the problem.

Topical ocular anaesthetic abuse in a contact lens wearer: a case of microbial keratitis

We describe the abuse of a topical ocular anaesthetic in a contact lens wearer who developed microbial keratitis.

Ring keratitis due to topical anaesthetic abuse in a contact lens wearer

A 38‐year‐old woman wearing hydrogel coloured contact lenses presented to the clinic with a painful red eye and epiphora. On biomicroscopy, a large corneal epithelial defect and ring infiltrate were observed. She had been using topical anaesthetic drops for 10-days. After cessation of the anaesthetic drops, the corneal lesions resolved completely in two weeks. On evaluation of a contact lens user with atypical keratitis, misuse of topical anaesthetics should also be considered.

Topical Anesthetic Abuse Keratopathy: A Commonly Overlooked Health Care Problem

To evaluate the clinical course, treatment modality, factors affecting the epithelization period, and visual outcome in patients with topical anesthetic abuse keratopathy. The medical records of 19 patients with a confirmed diagnosis of topical anesthetic abuse keratopathy were retrospectively examined; occupation, initiating event, biomicroscopic findings, treatment modality, epithelization period, and best-corrected visual acuity (BCVA) were noted. The Wilcoxon signed rank test was used to compare BCVA before and after treatment; P values <0.05 were considered statistically significant. In all, 26 eyes in 19 men aged 21-44 (mean age: 31 ± 6) years were included. Initiating events included exposure to arc welding flash (8 patients), metallic foreign body injury (8 patients), and chemical injury (3 patients). On admission to hospital, 10 patients (52.6%) reported that they were using topical anesthetics. Upon admission to the hospital, 10 patients (52.6%) self reported that they were using topical anesthetics. The remaining 9 subjects were discovered to be using topical anaesthetic drops during hospitalization. Twelve patients (63.2%) were found to continue using these agents during their hospitalization. Oval corneal epithelial defect, stromal infiltrate, ring-shaped keratitis, and hypopyon were noted in 100%, 46.2%, 57.7%, and 42.3% of the eyes, respectively. Topical antibiotics (fluoroquinolones or combined fortified cephalosporins and aminoglycosides), preservative-free lubricants/autologous serum, and bandage contact lens/eye patches were used for treatment. Mean epithelization period was 19.96 ± 11.16 days (range: 6-50 days). Mean pretreatment and posttreatment BCVA was 0.12 ± 0.16 (range: 0.001-0.7) and 0.66 ± 0.30 (range: 0.0-1.0), respectively (P < 0.001). Ophthalmologists should be suspicious of topical anesthetic abuse keratopathy in young male manual laborers specialized in welding business and foundry work presenting with persistent epithelial defects, ring-shaped keratitis, and accompanying severe ocular pain.

Topical Anesthetic Abuse Keratitis Secondary to Floppy Eyelid Syndrome

To report the diagnosis and management of a patient with chronic ophthalmic topical anesthetic abuse and floppy eyelid syndrome. We describe the case of a 47-year-old man suffering from persistent bilateral ocular irritation and chronic corneal erosions. The patient was hospitalized in our ophthalmology department and underwent thorough ophthalmic, systemic, and psychiatric evaluation. Chronic topical anesthetic abuse was discovered. Removal of abused drops and copious lubricating treatment lead to partial improvement further permitting diagnosis of floppy eyelid syndrome. Definitive surgical treatment by horizontal eyelid tightening combined with continuous lubrication resulted in remission of symptoms. Uncommon conditions may coexist in 1 patient. In this case, floppy eyelid syndrome resulted in topical anesthetic abuse. Ophthalmologists should keep both these conditions in mind when treating patients with otherwise unexplained chronic persistent corneal erosions.

Nonpreserved amniotic membrane transplantation for bilateral toxic keratopathy caused by topical anesthetic abuse: a case report

IntroductionCorneal damage associated with abuse of topical anesthetics is a rare clinic entity. Topical anesthetic abuse is one of the causes of ring keratitis. Ring keratitis is easily overlooked because it can mimic acanthamoeba keratitis or other infectious keratitis. The outcome is often poor, leading to persistent epithelial defects, corneal scarring, and perforations.Case presentationWe report the clinical presentation, diagnosis, and treatment of a 65-year-old Caucasian man, who worked as a health care worker, with bilateral toxic keratopathy caused by topical anesthetic abuse. Nonpreserved amniotic membrane transplantation was performed for both eyes of the patient.ConclusionIt is important to identify and treat patients who abuse topical anesthetics before permanent vision loss ensues. Nonpreserved amniotic membrane transplantation may be useful in relieving pain and improving corneal surface in anesthetic agent abusers.

Toxic keratopathy due to abuse of topical anesthetic drugs

Objective: To describe 8 cases of toxic keratopathy due to abuse of topical anesthetic drugs.Methods: Clinical findings from patients with toxic keratopathy were investigated retrospectively.Results: Two patients had toxic keratopathy bilaterally. Five of 8 patients had an ocular history of a corneal foreign body, 1 had basal membrane dystrophy, 1 had ultraviolet radiation, and 1 had chemical burn. All patients had undergone psychiatric consultation. Four patients had anxiety disorder and 1 had bipolar disease. Clinical signs were improved in all patients with discontinuation of topical anesthetic drug use along with adjunctive psychiatric treatment. Penetrating keratoplasty was performed in 2 patients.Conclusion: Toxic keratopathy due to topical anesthetic abuse is a curable disease. Early diagnosis and prevention of topical anesthetic drug use are the most important steps in the treatment of this condition. As these patients commonly exhibit psychiatric disorders, adjunctive psychiatric treatment may help to break the chemical addiction.