What are the treatment options for left eye watering and pain?

Treatment of Left Eye Watering and Pain

The first step is to perform a thorough ocular surface examination with slit-lamp biomicroscopy to identify the underlying cause—whether nociceptive (dry eye, inflammation, infection, trauma) or neuropathic—as this determines the treatment pathway. 1

Initial Diagnostic Approach

Key Clinical Features to Assess

• Discharge characteristics: Purulent discharge suggests bacterial infection; watery discharge may indicate viral, allergic, or dry eye disease 1, 2
• Pain quality: Burning pain with light sensitivity suggests neuropathic component; sharp pain with foreign body sensation indicates nociceptive causes 1
• Corneal findings: Epithelial defects, infiltrates, or staining patterns on fluorescein examination 1
• Tear film stability: Tear break-up time <10 seconds indicates dry eye 1
• Conjunctival appearance: Injection, chemosis, follicles, or papillae 1, 2

The Anesthetic Challenge Test

Instill topical proparacaine (0.5%) when pain is present: If pain improves, this indicates peripheral/nociceptive pain; if pain persists, suspect central neuropathic or nonocular pain 1

Treatment Algorithm Based on Etiology

For Bacterial Conjunctivitis/Keratitis

Mild bacterial conjunctivitis: Apply erythromycin ophthalmic ointment approximately 1 cm directly to the infected eye up to 6 times daily 3

Moderate-to-severe cases (copious purulent discharge, marked inflammation): Obtain cultures and start broad-spectrum topical antibiotics; consider MRSA coverage if risk factors present 1

For Dry Eye Disease with Pain

First-line therapy:

• Preservative-free artificial tears for symptomatic relief 1, 4
• Treat meibomian gland dysfunction with warm compresses and lid hygiene 1

Anti-inflammatory therapy (if inadequate response):

• Topical cyclosporine 0.05% 2-4 times daily 1
• Lifitegrast 5% twice daily 1, 4
• Short-term topical corticosteroids (loteprednol or preservative-free methylprednisolone 1%) for severe inflammation 1

Adjunctive measures:

• Punctal plugs to increase tear retention 1, 4
• Self-retained amniotic membrane (PROKERA) for rapid symptom relief in refractory cases 1

For Neuropathic Ocular Pain

Peripheral neuropathic pain (pain improves with anesthetic):

• Autologous serum tears 20% as topical nerve regenerative therapy 1
• Bandage contact lenses or scleral lenses (PROSE) to shield corneal nociceptors 1

Central neuropathic pain (pain persists despite anesthetic):

• Oral neuromodulators: Gabapentin, pregabalin, duloxetine, amitriptyline, or nortriptyline 1, 4
• Critical timing: Requires 3-4 months at therapeutic dose to see pain reduction; set expectations early 1

For light sensitivity and headache: Transcutaneous electrical nerve stimulation or periorbital botulinum toxin A injections 1, 4

For cutaneous allodynia: Periocular nerve blocks with corticosteroid plus long-acting sodium channel blocker 1

For Viral Conjunctivitis

Varicella zoster virus: Oral antivirals—acyclovir 800 mg 5 times daily for 7 days, valacyclovir 1000 mg every 8 hours for 7 days, or famciclovir 500 mg 3 times daily for 7 days 1

Molluscum contagiosum: Incision and curettage or excision of eyelid lesions (aggressive enough to cause bleeding) 1

For Allergic/Inflammatory Conditions

Allergic conjunctivitis: Mast-cell stabilizers, topical antihistamines 1

Superior limbic keratoconjunctivitis: Lubricants, cyclosporine 0.05%, soft contact lenses; check thyroid function (65% have thyroid dysfunction) 1

Critical Pitfalls to Avoid

• Do not ignore severe pain unrelieved by topical anesthetics—requires emergent ophthalmology referral for possible corneal ulcer, acute angle-closure, or scleritis 2
• Do not use fluorescein-anesthetic combination drops for tear break-up time testing, as anesthetic affects results 1
• Do not expect immediate relief with neuromodulators—patients need counseling that 3-4 months of treatment is required 1
• In patients with severe hyperalgesia, use preservative-free formulations as even low benzalkonium chloride concentrations are not tolerated 1

Multidisciplinary Considerations

For neuropathic ocular pain with psychological comorbidities (anxiety, depression common in 240+ patients): Consider cognitive behavioral therapy, acupuncture, or hypnosis alongside pharmacologic treatment 1, 4

Involvement of pain specialists, neurologists, and mental health professionals is warranted for holistic management of chronic neuropathic pain 1