What is the first-line treatment for eye pain?

First-Line Treatment for Eye Pain

Topical antibiotic eye drops are the first-line treatment for eye pain, particularly when associated with bacterial keratitis or corneal abrasion. 1

Treatment Algorithm Based on Cause of Eye Pain

1. Infectious/Inflammatory Causes

• Bacterial Keratitis

  • First-line: Topical fluoroquinolones (ciprofloxacin 0.3%, ofloxacin 0.3%, or levofloxacin 1.5%) 1
  • For severe cases: Fortified topical antibiotics with loading dose every 5-15 minutes followed by hourly applications
  • Add cycloplegic agents to decrease pain from anterior chamber inflammation

• Neuropathic Corneal Pain

  • First-line: Topical loteprednol 0.5% (author's preferred anti-inflammatory agent) 1
  • Dosing: Four times daily for two weeks, followed by twice daily for two weeks, then once daily over 6-12 weeks 2
  • For preservative sensitivity: Use preservative-free formulations like compounded methylprednisolone 1% 1

2. Non-infectious Causes

• Dry Eye-Related Pain

  • First-line: Artificial tears and lubricating ointments 3
  • Note: Patients with severe pain may have reduced response to standard dry eye treatments 3

• Neuropathic Pain

  • First-line: Tricyclic antidepressants (nortriptyline 10-25 mg at bedtime, increased every 3-7 days to 25-100 mg) 1
  • Alternative first-line: Gabapentin (100-200 mg/day initially) or pregabalin (25-50 mg/day initially) 1
  • For localized peripheral neuropathic pain: Topical lidocaine 1

Special Considerations

For Corneal Abrasions

• Topical antibiotics should be prescribed to prevent bacterial keratitis, especially for contact lens wearers 1
• Avoid patching or using bandage contact lenses in contact lens-associated abrasions due to increased risk of secondary bacterial keratitis 1

For Contact Lens Wearers

• Discontinue contact lens use immediately
• Higher risk of infection; require more aggressive antibiotic treatment 1
• Consider bandage contact lenses only with caution and close monitoring 1

For Severe Pain

• Add cycloplegic agents to decrease synechiae formation and reduce pain 1
• For breakthrough pain: Consider oral analgesics like acetaminophen 4
• Warning: Stop acetaminophen and consult doctor if pain worsens or lasts more than 10 days 4

Important Caveats

1. Urgent Ophthalmology Referral is necessary for:

   • Acute angle-closure glaucoma
   • Optic neuritis
   • Orbital cellulitis
   • Scleritis
   • Anterior uveitis
   • Infectious keratitis 5

2. Medication Side Effects:

   • Monitor for systemic absorption of ophthalmic medications, especially in elderly patients or those with cardiac conditions 6
   • TCAs require caution in patients with cardiac disease; limit dosage to <100 mg/day when possible 1
   • Gabapentinoids can cause somnolence, dizziness, and mental clouding, especially in older patients 1

3. Follow-up:

   • Regular monitoring is essential, especially when using bandage contact lenses 1
   • Early detection and appropriate treatment are crucial to minimize permanent visual loss 1

Remember that eye pain can be the first sign of an ophthalmologic emergency, so thorough evaluation and prompt treatment are essential to preserve vision and reduce morbidity 5.