Will Tordal (ketorolac) intramuscular (IM) injection help with eye pain?

Ketorolac IM for Eye Pain

Ketorolac intramuscular (IM) injection is not appropriate for treating eye pain, as it is indicated only for moderately severe acute pain requiring opioid-level analgesia in postoperative settings (typically non-ocular surgery), and topical ketorolac formulations are the evidence-based choice for ocular pain management. 1

Why IM Ketorolac is Not Indicated for Eye Pain

FDA-Approved Indications

• Ketorolac IM is approved exclusively for short-term management (≤5 days) of moderately severe acute pain requiring opioid-level analgesia, usually in postoperative settings 1
• The FDA label makes no mention of ocular pain as an indication 1
• The route of administration matters: systemic ketorolac via IM injection carries significant risks (GI bleeding, cardiovascular thrombotic events, renal toxicity) that are not justified for eye pain when safer topical alternatives exist 1

Contraindications and Safety Concerns

• Ketorolac IM is contraindicated in patients with active peptic ulcer disease, recent GI bleeding, advanced renal impairment, and carries black box warnings for serious cardiovascular events 1
• The combined duration of injectable and oral ketorolac cannot exceed 5 days due to increased risk of serious adverse events 1
• Elderly patients (≥65 years) face greater risk for serious GI events and require reduced dosing 1

Evidence-Based Treatment for Eye Pain

Topical Ketorolac is the Appropriate Formulation

• Topical ketorolac 0.5% (Acular) is specifically indicated for temporary relief of ocular itching caused by seasonal allergic conjunctivitis 2
• Topical NSAIDs reduce prostaglandin production involved in mediating ocular allergy and inflammation 2
• Research demonstrates topical ketorolac 0.4-0.5% significantly reduces postoperative ocular pain following cataract surgery and radial keratotomy 3, 4

Clinical Evidence for Topical Ketorolac

• In cataract surgery patients, topical ketorolac 0.4% reduced 24-hour postoperative pain, with only 4% reporting pain versus 39% with placebo (p=0.004) 3
• Following radial keratotomy, topical ketorolac provided significantly greater pain relief, shorter time to complete relief, and less need for oral analgesics compared to vehicle (p≤0.006) 4
• Topical ketorolac 0.5% was more effective than dexamethasone in reducing blood-aqueous barrier breakdown after cataract surgery 5

When Topical Ketorolac May Not Be Sufficient

• For neuropathic ocular pain (burning, stinging pain disproportionate to clinical findings), topical ketorolac alone is inadequate 2, 6, 7
• Neuropathic ocular pain requires a different treatment paradigm: autologous serum tears for peripheral component, oral neuromodulators (pregabalin, gabapentin, duloxetine, amitriptyline) for central component, and anti-inflammatory therapy with topical loteprednol 2, 6
• Systemic pharmacotherapy with gabapentinoids or SNRIs addresses central sensitization that topical agents cannot reach 2, 6, 8

Clinical Algorithm for Eye Pain Management

Step 1: Characterize the Pain

• Nociceptive pain (proportionate to clinical findings, acute onset): Consider topical ketorolac 0.5% QID 2, 3
• Neuropathic pain (burning/stinging, disproportionate to findings, photophobia, wind sensitivity): Requires multimodal approach with autologous serum tears and oral neuromodulators 2, 6, 7
• Allergic conjunctivitis: Topical ketorolac 0.5% for itching, or dual-action agents (antihistamine/mast cell stabilizers) for more comprehensive symptom control 2

Step 2: Select Appropriate Ketorolac Formulation

• Always use topical ketorolac for eye pain, never IM 2, 1
• Topical formulation provides direct ocular surface action with minimal systemic absorption 2
• IM ketorolac exposes patients to systemic risks without targeting the ocular surface effectively 1

Step 3: Consider Adjunctive Therapy

• For postoperative inflammation: Combine with topical corticosteroids (loteprednol 0.5% preferred for lower IOP risk) 2
• For severe hyperalgesia: Preservative-free formulations to avoid additional irritation 2
• For refractory cases: Autologous serum tears, bandage contact lenses, or referral to pain specialist 2, 6

Common Pitfalls to Avoid

• Do not use systemic NSAIDs (IM or oral) as first-line for eye pain when topical formulations are available and appropriate 2, 1
• Do not assume all eye pain is nociceptive; screen for neuropathic features (pain > signs, burning quality, photophobia) that require different management 6, 7
• Do not use topical ketorolac for laser photocoagulation pain, as evidence shows it is no more effective than artificial tears for this indication 9
• Do not overlook ocular surface comorbidities (dry eye, blepharitis, MGD) that may perpetuate pain and require concurrent treatment 2