C L I N I C A L A N D E X P E R I M E N TA L

RESEARCH PAPER

Effect of topical cyclopentolate on post-operative pain after pterygium

surgery

Clin Exp Optom 2017 DOI:10.1111/cxo.12513

Sertan Goktas* MD Objectives: The aim was to evaluate the effectiveness of topical cyclopentolate following
Yasar Sakarya† MD pterygium surgery for post-operative ocular pain.
Muammer Ozcimen† MD Methods: All participants had nasal pterygium and underwent pterygium excision and
Rabia Sakarya† MD conjunctival autografting with fibrin glue. Participants were randomised into two groups.
Ismail Alpfidan† MD Participants in group 1 received one per cent cyclopentolate eye drops and artificial
Ismail Senol Ivacık† MD tears upon completing surgery and were prescribed self-administered drops three times
Erkan Erdogan† MD daily for three days, while participants in group 2 received a control (artificial tears) in a
*Department of Opthalmology, Kayseri Training and manner identical to group 1. Data were gathered regarding post-operative pain intensity
Research Hospital, Kayseri, Turkey experienced during each of the three days. Pain was graded from zero to 10 according
†
Department of Opthalmology, Konya Training and
to a visual analogue scale, in which zero signified no pain and 10 signified severe,
Research Hospital, Konya, Turkey
E-mail: drsertandr@gmail.com unbearable pain.
Results: This study analysed data regarding 38 participants in group 1 and 40 participants
in group 2. Results were defined as median with interquartile range (IQR); median of the
pain scores at days one, two and three were as follows, respectively: 4 (IQR 2), 2.5 (IQR 1)
and 2 (IQR 1.25) for group 1 and 5 (IQR 1), 3 (IQR 1.75) and 3 (IQR 1) for group 2. Pain
Submitted: 26 July 2016 scores were significantly lower for group 1 compared with group 2 at days one, two and
Revised: 5 October 2016 three (p < 0.05).
Accepted for publication: 11 November Conclusions: Topical cyclopentolate seems to be effective and well tolerated following
2016 pterygium surgery for post-operative ocular pain.

Key words: cyclopentolate, pain, pterygium surgery

A pterygium is a commonly occurring ocular
surface disorder, in which a wing-shaped
fibrovascular conjunctival growth extends
onto the cornea. Conditions that justify sur-
gical intervention include diminished visual
acuity, patient discomfort, ocular motility
restriction and dysplastic lesions, as well as
cosmetic purposes.1 Surgical excision is the
primary method for treating pterygium.
Among the treatments, conjunctival auto-
graft with fibrin glue appears to be optimal
due to its efficiency and low rates of both sur-
gical complications and recurrence.2
Nevertheless, the most common post-
operative complaint after surgery for ptery-
gium is significant ocular pain. Although
various prescribed medications are availa-
ble to manage post-operative ocular pain
and discomfort, patients may still feel
pain in variable degrees post-operatively.3,4
Novel medications and/or procedures are
desired to decrease pain in patients who
have undergone pterygium surgery.
Cycloplegic drugs are generally pre-
scribed to relieve the ciliary muscle spasm
thought to occur in patients with corneal
surface problems, such as corneal abrasions
and recurrent erosions.5 Complete excision
of a pterygium from the cornea and sclera,
which subsequently leaves a denuded cor-
neoscleral surface, is the main surgical pro-
cedure during pterygium surgery. From
these findings, we speculated that cyclople-
gics may be used as an adjunctive treat-
ment to relieve pain following pterygium
surgery.
This study aimed to evaluate the effec-
tiveness of topical cyclopentolate after pter-
ygium surgery for the relief of post-
operative ocular pain.
METHODS
This study was conducted at the Depart-
ment of Ophthalmology, Konya Training
and Research Hospital, Konya, Turkey. All
participants were patients enrolled after
having had primary nasal pterygium. Nei-
ther systemic analgesic nor topical non-
steroidal anti-inflammatory drops were
administered preoperatively. Exclusion cri-
teria included diseases of the immune sys-
tem, eyelid or ocular surface, history of
previous ocular surgery or trauma, collagen
vascular disease or diabetes mellitus and
hypersensitivity to any component of fibrin
glue. If the patients required additional
anaesthesia because of significant pain
post-operatively, they were excluded from
the study.
Participants were given written informa-
tion detailing the surgical procedure and
study. The study received approval from
the local ethics committee and was con-
ducted in accordance with the tenets of the
Declaration of Helsinki. Informed consent
was obtained from all participants.
The area of surgery to be operated upon
was sterilised with 10 per cent povidone
iodine. After administering a topical
0.5 per cent proparacaine hydrochloride
(Alcaine, Alcon, Rotkreuz, Switzerland), an
ocular speculum was put into place. Sur-
gery was performed under an operating

© 2017 Optometry Australia Clinical and Experimental Optometry 2017

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Cyclopentolate for pterygium surgery Goktas, Sakarya, Ozcimen, Sakarya, Alpfidan, Ivacık and Erdogan
microscope and subconjunctival anaesthe-
sia was applied using a 27-gauge needle
(0.5 ml two per cent lidocaine hydrochlo-
ride and adrenaline 0.001 per cent, Jeto-
kaine, Adeka AS, Samsun, Turkey) beneath
the body of the pterygium. The head of the
pterygium was cut at the limbus and
removed from the corneal surface with
blunt dissection. Although the cornea can
be gently scraped with a blade to ensure
the removal of all surface cells, excellent
polishing and smoothing of the surface was
achieved with a diamond-tipped drill. Mini-
mal cauterisation was applied to control
bleeding. A conjunctival graft without
Tenon’s tissue (superotemporal bulbar
conjunctiva) was prepared, excised and
spread upon the cornea. The graft was sub-
sequently attached to the bare sclera with
fibrin glue. The fibrin glue (Tisseel, Two-
Component Fibrin Sealant Vapor Heated,
Baxter Healthcare Corporation, Glendale,
California, USA) was prepared according
to the manufacturer’s directions. The
fibrin glue has two components, each of
which was drawn out into two separate one
mL syringes. One drop of thrombin com-
ponent was placed on the scleral bed, to
which one drop of protein solution was
immediately added. The graft was slid over
and pressed gently onto the scleral bed.
The graft was held in position for up to
three minutes, until the fibrin glue was
firmly set to prevent tissue displacement.
Finally the lid speculum was carefully
removed.
The patients were randomised into two
groups by a simple randomisation tech-
nique. For the members of group 1, one
per cent cyclopentolate eye drops
(Sikloplejin, Abdi İbrahim, Ankara, Tur-
key) and artificial tears (Protagent, Liba,
Ankara, Turkey) were administered at the
end of surgery and prescribed to be self-
administered three times daily for three
days after surgery. For the members of
group 2, artificial tears were administered
in a manner identical to group 1 as con-
trols. Both groups also received topical
0.1 per cent fluorometholone (FML; Aller-
gan, Istanbul, Turkey) and 0.3 per cent
Group 1 (n = 38)
Mean age ± SD 39  3.6
Female/male 15/23
Table 1. Demographic features of the patients
Clinical and Experimental Optometry 2017
2
ciprofloxacin (Ciloxan, Alcon, Istanbul,
Turkey) four times daily after surgery. If
the patients became intolerant to pain
post-operatively despite the above medica-
tion, we planned to offer oral analgesia.
Data were collected regarding the pain
experienced at days one, two and three
after the operation. Pain was graded from
zero to 10 according to a visual analogue
scale in which zero signified no pain and
10 signified severe, unbearable pain.
A trained examiner recorded the subjective
pain scores. Neither the examiner nor the
participants knew which participants had
received topical cyclopentolate eye drops.
Statistical analysis was performed with
SPSS version 15 (SPSS Inc., Chicago, Illi-
nois, USA). Demographic data were com-
pared between the two groups using a Chi-
square test. To assess the correlation of the
data with normal distribution, the
Kolmogorov–Smirnov test was used. For
parametric data analyses, Student’s t-test
was used. Post-operative pain scores in each
group were defined as median with inter-
quartile range and were compared with
Mann–Whitney U-test. A p-value of less
than 0.05 was considered statistically
significant.
RESULTS
Group 1 included 38 participants
(15 female) and showed a mean age of
39  3.6 years (range 19 to 44 years). Of
the 40 members of group 2, 17 were female
and the mean age was 37  5.4 years
(range 21 to 45 years). Demographic data
for both groups are summarised in
Table 1. There were no statistically signifi-
cant differences in mean age or gender
between the two groups (p > 0.05;
Table 1). The mean extension of the ptery-
gia onto the cornea was 3.02  0.71 mm in
group 1 and 2.89  0.50 mm in group
2. The extension of the pterygia did not
differ between groups (p = 0.358).
No participants in either treatment
group reported a pain score of zero.
Median of the pain scores at days one, two
Group 2 (n = 40) p sustained through day three. This is partic-
37  5.4 0.136
17/23 0.249
and three were as follows, respectively:
4, 2.5 and 2 for group 1 and 5, 3 and 3 for
group 2. Pain scores were significantly
lower for group 1 compared with group
2 at days one, two and three (p < 0.05).
Pain scores are summarised in Table 2. No
local or systemic adverse events resulting
from the topical cyclopentolate were
observed in group 1.
All of our patients completed the opera-
tions with their designated treatment.
None of the patients required additional
anaesthetic during the post-operative
period.
DISCUSSION
Surgery for pterygium causes significant
post-operative ocular pain. This pain is
likely to originate from both the cornea
and conjunctiva.3,4 At the same time, man-
aging a post-operative pain regimen
remains controversial, although a few stud-
ies have mentioned the management of
pain after pterygium surgery.
Corneal lesions such as corneal abrasions
and recurrent erosions cause pain in the
corneal sensory nerve fibres of the affected
cornea and pain translates internally.5 Fur-
ther, keratitis causes ocular pain, which
may be related to ciliary spasm secondary
to the corneal neuronal reflex.6 To relieve
ciliary muscle spasms thought to occur in
patients with corneal surface problems,
cycloplegic drugs are generally pre-
scribed.5,6 Cycloplegic drugs do nothing
for nerve pain from the cornea but they
help reduce the ciliary spasm and make
patients a little more comfortable. Com-
plete excision of a pterygium from the cor-
nea and sclera, which subsequently leaves a
denuded corneoscleral surface is the chief
surgical procedure. On the basis of the
aforementioned data, in this study, we have
evaluated the effect of topical cyclopento-
late as an adjunctive treatment to decrease
pain after surgery for pterygium.
This study revealed that pain scores at
each recorded time were significantly
reduced in the cyclopentolate group com-
pared with the control group. The benefits
of treatment were observed at day one and
ularly impressive, as no other analgesic
agents were used in this study. This study
suggests that the use of topical cyclopento-
late may be helpful in pain management
after pterygium surgery but a properly con-
trolled study with a larger sample is
© 2017 Optometry Australia
 Cyclopentolate for pterygium surgery Goktas, Sakarya, Ozcimen, Sakarya, Alpfidan, Ivacık and Erdogan
Group 1
Median interquartile range
Day 1 4–2
Day 2 2.5–1.0
Day 3 2.00–1.25
Table 2. Post-operative pain scores in each group
required to confirm this. No studies have
reported the effect of cycloplegic drugs for
pain following surgery for pterygium.
Studies have reported using various medi-
cations for post-operative analgesia after
pterygium surgery, one of which is viscous
lidocaine gel. One particular study con-
cluded that topical lidocaine gel is an effec-
tive and safe anaesthetic agent to control the
pain experienced shortly after pterygium
surgery;4 however, lidocaine gel could
reduce the effectiveness of povidone iodine,
which may produce a substantial increase in
risk of acute post-operative infection.7 Topi-
cal anaesthetic may cause serious complica-
tions, such as delayed wound healing,
persistent epithelial defects, corneal ulcera-
tion, corneal oedema and keratitis,8,9 the last
of which surgeons must regularly examine
patients post-operatively for early identifica-
tion. These complications limit the useful-
ness of topical anaesthetic to control pain
after pterygium surgery. Another limitation
of this particular study was that its follow-up
period (10 hours) was too brief to evaluate
the effectiveness of medication for post-
operative pain. In contrast, the follow-up
period of the present study was three days,
which was long enough to reach
conclusions.
In another study, orbital morphine was
applied as analgesia after pterygium surgery.3
Orbital morphine was given by peribulbar
injection, an invasive procedure that can
cause serious complications (for example,
optic nerve injury, retrobulbar haemorrhage
© 2017 Optometry Australia
Group 2 p 1. Hirst LW. The treatment of pterygium. Surv
Median interquartile range
5–1 0.006
3.00–1.75 0.005
3–1 0.002
and globe perforation),10 thereby reducing
this procedure’s usefulness.
Topical non-steroidal anti-inflammatory
drops have also been used to reduce pain
after ocular surgery;11 however, these drops
may cause corneal surface problems, such
as slower healing and corneal damage.
Additionally, corneal melting, superficial
punctate keratitis, corneal infiltrates and
epithelial defects have been reported fol-
lowing the administration of topical non-
steroidal anti-inflammatory drops.12
Cycloplegics are known as anticholiner-
gics that block the action of acetylcholine.
In the eye, acetylcholine receptors are
located within the iris sphincter muscle as
well as in the ciliary body. The activity of
these receptors results in the contraction of
the iris and ciliary body. Cycloplegics tem-
porarily inhibit this activity, thereby causing
ciliary body paralysis and pupillary mydria-
sis.13 Cycloplegics can induce acute angle-
closure glaucoma as a mydriatic effect of
these agents; however, a shallow anterior
chamber is a risk factor that should be eval-
uated before cycloplegia.14 Although
uncommon, cycloplegics may induce men-
tal and neurotoxic effects.15 We used cyclo-
pentolate in low doses over a brief period
and did not observe complications related
to the use of cycloplegics.
In conclusion, the results of this study
indicate that topical cyclopentolate seems
to be effective and well tolerated following
surgery for pterygium for post-operative
ocular pain.
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