Generic Name

Ketorolac

Mechanism

Ketorolac inhibits cyclooxygenase‑1 (COX‑1) and cyclooxygenase‑2 (COX‑2) in ocular tissues, reducing the synthesis of prostaglandin E₂ and other inflammatory mediators.
• ↓ prostaglandin levels → ↓ vasodilation, vascular permeability, and leukocyte chemotaxis.
• Rapid onset of local analgesia due to direct ocular surface penetration and minimal systemic exposure.

Pharmacokinetics

• Absorption: Primarily local; ocular surface penetration is most efficient; systemic absorption is <5 % of a single drop.
• Distribution: Concentration peaks in corneal epithelial cells within 15–30 min; low aqueous humor levels (<0.5 % of dose).
• Metabolism: Minimal first‑pass; largely unchanged in ocular tissues.
• Elimination: Excreted via lacrimal drainage and conjunctival epithelium; ocular half‑life ~1.7 h.
• Drug‑Drug Interactions: Rare ocular interactions; systemic NSAID interaction risk only at high cumulative exposure.

Indications

• Post‑operative pain & inflammation after cataract extraction, phacoemulsification, laser refractive surgeries (LASIK, PRK), mechanical corneal trauma, and low‑dose intraocular procedures.

Contraindications

• Contraindicated in patients with:

* Hypersensitivity to ketorolac, other NSAIDs, or any excipient.

* Active ocular surface disease, corneal ulceration, or infection.
• Warnings

* Avoid in patients with severe renal or hepatic impairment due to potential systemic absorption.

* Use cautiously in patients with history of gastrointestinal ulceration or bleeding disorders.

* Long‑term (>2 weeks) use can worsen corneal epithelial healing and worsen dry‑eye disease.

Dosing

• Standard regimen: 1–2 drops in the affected eye q6–8 h (maximum 8 drops/day) for up to 5 days.
• Adjunctive instructions:

1. Shake bottle gently.

2. Sweep eye to lower lid.

3. Avoid touching the dropper tip to ocular surface.

4. Close eye for ~30 s; blink at least 8–10 times to aid distribution.
• Special populations: No dosage adjustment required for pediatric, geriatric, or renal‑impaired patients when used topically.

Adverse Effects

Common
• Burning, stinging, photophobia, irritation, blurred vision.

Serious
• Corneal epithelial erosion, neurotrophic keratitis, corneal ulceration, ocular hypersensitivity reactions, systemic NSAID‑related GI or renal events in rare cases of high systemic absorption.

Monitoring

• Ocular:

* Check for signs of corneal epithelial breakdown (scratch, ulcer).

* Evaluate pain relief and inflammation control.

* Intraocular pressure monitoring if concomitant anti‑glaucoma therapy is used.
• Systemic (if risk factors present):

* Renal function (serum creatinine/BUN).

* GI symptoms if patient takes systemic NSAIDs concurrently.

Clinical Pearls

• Only PSA‑worthy: Ketorolac ophthalmic is the *only* ocular NSAID specifically approved for postoperative pain after corneal refractive surgery in the U.S., offering the best pain control with minimal systemic exposure.
• Use for combined therapy: Pair with lubricating drops to mitigate stinging and support corneal healing.
• Timing matters: Initiate within 4 h post‑procedure to maximize anti‑inflammatory benefit; prolonged use >10 days increases corneal toxicity risk.
• Non‑surgical use limited: Avoid prescribing solely for dry‑eye or allergic conjunctivitis—OTC NSAID eye drops (e.g., diclofenac) are usually preferred.
• Contraindications highlight: A gentle reminder that patients with diabetes or microvascular disease are more prone to neurotrophic keratitis; consider alternative NSAID ophthalmic products if high risk.
• Patient education tip: Instruct patients to space ketorolac drops at least 10 minutes apart if using additional ophthalmic agents in the same eye.

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• Ketorolac ophthalmic delivers rapid, targeted anti‑pain and anti‑inflammatory effects with a favorable safety profile when used within the recommended time frame, making it a cornerstone therapy for postoperative ocular care.