What is the recommended use and dosage of ketorolac (nonsteroidal anti-inflammatory drug (NSAID)) eye drops?

Ketorolac Eye Drops: Recommended Use and Dosage

Ketorolac tromethamine ophthalmic solution is FDA-approved at one drop four times daily for two primary indications: relief of ocular itching due to seasonal allergic conjunctivitis, and treatment of postoperative inflammation following cataract extraction (starting 24 hours after surgery and continuing through the first 2 weeks postoperatively). 1

FDA-Approved Indications and Dosing

Seasonal Allergic Conjunctivitis

• Dose: One drop (0.25 mg) four times daily for relief of ocular itching 1
• Ketorolac is indicated specifically for temporary relief of ocular itching caused by seasonal allergic conjunctivitis 2

Postoperative Inflammation After Cataract Surgery

• Dose: One drop four times daily to the affected eye(s) 1
• Timing: Begin 24 hours after cataract surgery 1
• Duration: Continue through the first 2 weeks of the postoperative period 1
• Ketorolac 0.4% has demonstrated equivalent efficacy to ketorolac 0.5% in controlling inflammation after cataract surgery, including prevention of cystoid macular edema 3

Clinical Evidence Supporting Use

Efficacy in Postoperative Inflammation

• Ketorolac 0.5% solution demonstrated comparable effectiveness to dexamethasone 0.1% in suppressing postoperative inflammation after cataract surgery, as measured by fluorophotometry and slit-lamp examination 4
• In patients with moderate to severe anterior segment inflammation after cataract surgery, ketorolac was significantly more effective than vehicle in reducing anterior chamber cells (P ≤ 0.030), flare (P ≤ 0.025), conjunctival erythema (P ≤ 0.046), ciliary flush (P ≤ 0.006), tearing (P ≤ 0.012), photophobia (P ≤ 0.014), and pain (P ≤ 0.049) 5
• Half as many patients in the ketorolac group (14/51) required discontinuation for lack of efficacy compared to vehicle (28/51; P = 0.005) 5

Pain Control in Refractive Surgery

• A single preoperative dose of ketorolac 0.5% (administered 30 minutes before PRK) significantly reduced pain scores on visual analogue scale on postoperative days 1 and 2 6
• Ketorolac also reduced ocular discomfort including foreign body sensation, itching, tearing, and photophobia following PRK 6
• The American Academy of Ophthalmology recognizes that postoperative pain after PRK is typically reduced using bandage contact lenses and NSAID drops 2

Integration with Other Postoperative Medications

Ketorolac can be safely administered in conjunction with other ophthalmic medications including antibiotics, beta blockers, carbonic anhydrase inhibitors, cycloplegics, and mydriatics. 1

Combination with Corticosteroids

• Topical NSAIDs like ketorolac are recommended within the first post-surgical month as part of comprehensive postoperative management, particularly when combined with preservative-free formulations 7
• NSAIDs should be used alongside topical steroids and preservative-free artificial tears for optimal outcomes 7
• Topical corticosteroids are generally started immediately after refractive surgery and tapered over days to weeks 2

Critical Safety Considerations and Pitfalls

Risk of Delayed Corneal Epithelialization

• NSAID drops may delay corneal epithelialization and should be prescribed judiciously 2
• This is particularly relevant in surface ablation procedures like PRK where epithelial healing is critical 2

Risk of Sterile Corneal Infiltrates

• Sterile corneal infiltrates have been described with NSAID drops when used without concomitant topical corticosteroids 2
• Always consider microbial keratitis whenever a corneal infiltrate is seen, as NSAIDs provide no antimicrobial coverage 2

Not a Substitute for Antibiotics

• Ketorolac is NOT indicated as monotherapy for bacterial keratitis or other infectious conditions 7
• It provides no antimicrobial coverage and should never replace appropriate antibiotic therapy for corneal ulcers or keratitis 7
• When infection risk exists alongside inflammation, combination products with antibiotics are more appropriate than ketorolac alone 7

Monitoring Requirements

• Postoperative follow-up should occur on day 1, during weeks 1-2, and at 1 month to evaluate treatment effect 7
• Close supervision is warranted when NSAIDs are used, particularly in the context of surface ablation procedures 2

Mechanism and Pharmacology

• Ketorolac is a non-steroidal agent with potent analgesic and moderate anti-inflammatory activity 8
• It reduces prostaglandin production involved in mediating ocular inflammation and allergy 2
• The reformulated 0.4% concentration contains 20% less active ingredient than the original 0.5% formulation while maintaining equivalent efficacy 3