How should ketorolac ophthalmic (0.5% ketorolac tromethamine) be used for ocular pain and inflammation, including dosage, contraindications, and adverse effects?

Ketorolac Ophthalmic 0.5%: Clinical Use for Ocular Pain and Inflammation

Primary Indications and Dosing

Ketorolac tromethamine 0.5% ophthalmic solution is indicated for reducing ocular pain and inflammation following cataract surgery and for treating ocular pain and burning/stinging after corneal refractive surgery, administered four times daily for up to 2-4 weeks maximum. 1

Standard Dosing Regimen

• Instill one drop four times daily in the affected eye(s) beginning 24 hours after cataract surgery and continuing for 14 days postoperatively 2
• For refractive surgery, initiate dosing on postoperative day 1 and continue for the prescribed duration 3, 4
• The reformulated 0.4% concentration demonstrates equivalent efficacy to 0.5% with 20% less active ingredient, though 0.5% remains widely used 3, 4

Clinical Efficacy Evidence

• Ketorolac 0.5% significantly reduces anterior chamber cells (P = 0.002), flare (P = 0.009), conjunctival erythema (P = 0.010), ciliary flush (P = 0.022), photophobia (P = 0.027), and pain (P = 0.043) compared to vehicle after cataract surgery 2
• Five times fewer patients required discontinuation for lack of efficacy with ketorolac (4/52) versus vehicle (22/52; P = 0.001) 2

Contraindications and Precautions

Absolute Contraindications

• Do not use ketorolac ophthalmic in patients with active viral conjunctivitis (especially herpes simplex or adenovirus), as NSAIDs do not treat viral infections and may delay appropriate antiviral therapy 5, 6
• Avoid in patients with known hypersensitivity to ketorolac, aspirin, or other NSAIDs 1

Critical Safety Warnings

• All topical NSAIDs carry risk of severe corneal complications including keratitis, corneal thinning, corneal erosion, corneal ulceration, and corneal perforation with continued use beyond recommended duration 1
• The maximum recommended duration is 2-4 weeks to avoid serious adverse events; extended use requires ophthalmology supervision 1

Clinical Situations Requiring Caution

• Patients with complicated ocular surgeries, corneal denervation, corneal epithelial defects, diabetes mellitus, ocular surface diseases (e.g., dry eye syndrome), rheumatoid arthritis, or repeat ocular surgeries within a short period have increased risk of corneal adverse events 1
• Concomitant use of topical corticosteroids may increase the potential for healing problems 1

Adverse Effects Profile

Common Adverse Effects

• Transient burning or stinging on instillation occurs in approximately 1.5% of patients 7
• Overall adverse event rates are actually lower with ketorolac (35.2%) than vehicle placebo (48.5%; P = 0.004) in clinical trials 7

Serious Adverse Effects Requiring Immediate Discontinuation

• Any signs of corneal epithelial breakdown, corneal thinning, erosion, or ulceration mandate immediate cessation and urgent ophthalmology referral 1
• Development of keratitis requires discontinuation and specialist evaluation 1

Drug Interactions and Compatibility

• Ketorolac can be safely administered with other ophthalmic medications including antibiotics and beta-blockers, with no significant interactions reported 1
• When using multiple topical ophthalmic agents, separate administration by at least 5 minutes to prevent dilution 1

Alternative NSAID Formulations

• Ketorolac 0.4% ophthalmic solution demonstrates equivalent efficacy to 0.5% for controlling postoperative inflammation and preventing cystoid macular edema 3, 4
• Ketorolac 0.45% preservative-free formulation administered twice daily effectively treats inflammation and pain, with 52.5% of patients achieving zero inflammation score on day 14 versus 26.5% with vehicle (P < 0.001) 7, 8
• Nepafenac 0.1% three times daily represents an alternative NSAID option, though evidence is more limited 1

Clinical Pitfalls to Avoid

• Never continue topical NSAIDs beyond 2-4 weeks without ophthalmology consultation, as chronic use dramatically increases risk of corneal perforation 1
• Do not use ketorolac as monotherapy for bacterial conjunctivitis; it provides no antimicrobial activity and delays appropriate antibiotic treatment 5, 6
• Avoid prescribing ketorolac for viral conjunctivitis, as supportive care with preservative-free artificial tears is the appropriate management 5, 6
• For chronic inflammatory conditions requiring treatment beyond 2-4 weeks, consider transitioning to topical corticosteroids under ophthalmology supervision rather than prolonging NSAID therapy 1

Appropriate Clinical Scenarios for Use

• Postoperative inflammation and pain control following cataract extraction with intraocular lens implantation 2, 4
• Ocular pain and burning/stinging following corneal refractive surgery (PRK, LASIK) 3, 4
• Prevention and treatment of cystoid macular edema when used both pre- and postoperatively 3, 4
• Inhibition of intraoperative miosis during cataract surgery 3, 4
• Second-line treatment for ocular itching caused by seasonal allergic conjunctivitis (after dual-action antihistamine/mast cell stabilizers) 1