Ketorolac for Corneal Abrasion Pain Management
Topical ketorolac 0.5% is an effective and safe option for pain control in simple, traumatic corneal abrasions, but must be used with caution and discontinued immediately if any signs of corneal complications develop.
Evidence-Based Recommendation
Topical NSAIDs like ketorolac significantly reduce pain and the need for oral analgesics in the first 24-48 hours after corneal abrasion, without delaying healing in uncomplicated cases. 1
Pain Control Efficacy
- Ketorolac 0.5% ophthalmic solution provides significantly decreased pain, photophobia, and foreign body sensation at 24 hours compared to placebo 2
- Patients using topical NSAIDs require 53% less oral analgesic medication (95% CI 34-67% reduction) compared to control groups 1
- Pain reduction is sustained through 48 hours with standardized mean differences of -0.69 at 24 hours and -0.56 at 48 hours 1
- Time to resumption of normal activities is significantly shorter with ketorolac treatment 2
Healing and Safety Profile
- No difference in healing rates has been demonstrated - approximately 90% of abrasions heal within 24 hours and all by 48 hours regardless of NSAID use 3
- Complications are rare in simple traumatic abrasions, with no significant increase in adverse events compared to controls in properly selected patients 1
Critical Safety Considerations and Contraindications
Absolute Requirements Before Prescribing
- Only use for non-contact lens related, non-infected traumatic corneal abrasions 4, 2
- Confirm absence of infection through slit-lamp examination with fluorescein staining 5
- Rule out contact lens wear as the cause - these patients require topical antibiotics and are at higher risk for bacterial keratitis 4
Serious Risks Requiring Immediate Discontinuation
The FDA label warns that topical NSAIDs can cause corneal erosion, corneal perforation, corneal thinning, and epithelial breakdown 6. These complications, while rare, are vision-threatening.
- Discontinue ketorolac immediately if any signs of corneal melt, increased thinning, or delayed healing develop 7
- NSAIDs cause corneal complications through epithelial desquamation and stromal collagen degradation via matrix metalloproteinase activation 7
- Monitor closely for progression of epithelial defect size or development of stromal involvement 7
Practical Treatment Algorithm
Patient Selection (Must Meet ALL Criteria)
- Simple traumatic corneal abrasion or post-foreign body removal
- No contact lens wear involvement
- No signs of infection (no infiltrate, no significant anterior chamber reaction)
- No pre-existing corneal disease or dry eye
- Follow-up available within 24-48 hours
Dosing Protocol
- Ketorolac tromethamine 0.5% ophthalmic solution: 1 drop four times daily 2
- Limit duration to 48-72 hours maximum - short courses minimize risk of corneal complications 4
- Combine with topical antibiotic (erythromycin or polymyxin B ointment) 2
- Add cycloplegic agent (cyclopentolate 0.5%) for patient comfort 8
Mandatory Follow-Up
- Re-evaluate within 24-48 hours to assess healing and rule out complications 9
- At follow-up, assess for: progression of epithelial defect, signs of infection, stromal involvement, and any delayed healing 7
- If abrasion not significantly improved or any concerning features develop, discontinue NSAID immediately 7
Common Pitfalls to Avoid
- Never use topical NSAIDs in contact lens-related abrasions - these require antibiotic prophylaxis and have higher infection risk 4
- Do not continue NSAIDs beyond 72 hours - prolonged use increases risk of corneal melting complications 4, 7
- Avoid in patients with poor follow-up - complications require prompt recognition and management 9
- Do not use if any suspicion of infection exists - NSAIDs can mask inflammatory signs and worsen outcomes 5
- Never combine with pressure patching - patching increases infection risk and is ineffective for pain control 4, 1