What is the treatment for bilateral periorbital pain?

Treatment for Bilateral Periorbital Pain

Bilateral periorbital pain treatment should follow a stepwise approach targeting the underlying neuropathic ocular pain (NOP) mechanisms, beginning with peripheral treatments and progressing to systemic therapies as needed. 1, 2

Diagnosis and Evaluation

First, determine the source of pain using:

• Anesthetic challenge test: Apply topical anesthetic - if pain improves, this suggests peripheral/nociceptive pain; if no improvement, suggests central or non-ocular origin 1, 2
• Evaluate tear film parameters and ocular surface for:
  • Aqueous tear deficiency
  • Tear film instability (tear break-up time test)
  • Inflammation
  • Epithelial erosions 1
• Consider specialized questionnaires like NPSI-Eye or OPAS to identify neuropathic pain qualities 2

Treatment Algorithm

Step 1: Peripheral Pain Treatment

For peripheral neuropathic ocular pain:

• Topical nerve regenerative therapies:

  • Autologous serum tears 1, 2
  • Preservative-free artificial tears 2

• Anti-inflammatory therapy:

  • Loteprednol 0.5% (preferred due to lower side effect profile): 4 times daily for 2 weeks, then twice daily for 2 weeks, then once daily for 6-12 weeks 1
  • For patients with severe hyperalgesia: preservative-free formulations like compounded methylprednisolone 1% 1

• Ocular surface rehabilitation:

  • Emulsion-based lubricants
  • Treatment for meibomian gland dysfunction: hot compresses, lid massage
  • Moisture chamber goggles 1
  • Consider punctal plugs after inflammation is controlled 1

Step 2: Protective Measures

If pain persists:

• Bandage contact lenses or scleral lenses to shield corneal nociceptors from external stimuli 1
• Cryopreserved amniotic membrane (CAM) for anti-inflammatory and neurotrophic effects 1

Step 3: Systemic Therapy for Central or Refractory Pain

For central neuropathic pain or persistent symptoms:

• First-line oral neuromodulators:

  • Nortriptyline: Start 10-25mg at bedtime, increase every 3-7 days to 25-100mg as tolerated 1
  • Pregabalin or gabapentin 1
  • Duloxetine, amitriptyline, or low-dose naltrexone 1

• Adjunctive treatments:

  • Periorbital botulinum toxin A injections for light sensitivity and headache 1
  • Periocular nerve blocks (supraorbital, supratrochlear, infraorbital, infratrochlear) with corticosteroid and long-acting sodium channel blocker for cutaneous allodynia or postsurgical pain 1, 3
  • Transcutaneous electrical nerve stimulation devices 1

Important Considerations

• Timeframe for relief: Neuromodulators require 3-4 months at therapeutic doses to show pain reduction - set appropriate expectations 1

• Combination approaches: Often multiple modalities are needed simultaneously 1

• Avoid triggers: In patients with severe hyperalgesia, even low concentrations of preservatives like BAK can exacerbate symptoms 1

• Address psychological aspects: Consider complementary therapies like acupuncture, cognitive behavioral therapy, or hypnosis for concomitant anxiety and depression 1

When to Consider Multidisciplinary Approach

For complex or refractory cases, involve:

• Pain specialists
• Neurologists
• Mental health professionals 1, 2

Caution

• Avoid NSAIDs like ibuprofen or naproxen as primary treatment, as they may cause periorbital edema in some patients 4
• Rule out other causes of periorbital pain such as trochlear headache, which requires specific diagnosis and treatment 5
• Consider dermatological causes if skin manifestations are present 6