What are the treatment options for eye pain and pressure?

Treatment of Eye Pain and Pressure

For eye pain and pressure, treatment must be directed at the underlying cause after ruling out vision-threatening emergencies like acute angle-closure glaucoma, which requires immediate ophthalmology referral and pressure-lowering medications. 1, 2

Emergency Conditions Requiring Immediate Treatment

Acute Angle-Closure Glaucoma

• This is a vision-threatening emergency requiring immediate ophthalmology referral and treatment with topical timolol maleate 0.25-0.5% twice daily to lower intraocular pressure. 1, 2
• Timolol dosing starts at 0.25% one drop twice daily in affected eye(s), escalating to 0.5% if inadequate response after 4 weeks of pressure monitoring. 1
• Concomitant therapy with additional pressure-lowering agents may be needed if monotherapy fails. 1

Other Emergent Causes

• Orbital cellulitis, infectious keratitis, scleritis, anterior uveitis, and optic neuritis all require urgent ophthalmology consultation. 2
• Giant cell arteritis requires urgent corticosteroid treatment despite presenting with a quiet eye. 3

Non-Emergency Ocular Surface Conditions

Dry Eye and Ocular Surface Disease

• Begin with warm compresses for several minutes to soften meibomian secretions, followed by gentle eyelid massage and cleansing with diluted baby shampoo or hypochlorous acid 0.01% cleaners. 4
• This regimen should be performed once or twice daily and may be required long-term as symptoms recur when discontinued. 4
• Add preservative-free artificial tears for aqueous deficiency and emulsion-based lubricants for evaporative dry eye. 4
• Patients with advanced glaucoma should avoid aggressive lid pressure during massage as it may increase intraocular pressure. 4

Blepharitis and Meibomian Gland Dysfunction

• Topical antibiotic ointment (bacitracin or erythromycin) applied to lid margins once daily or at bedtime for several weeks provides symptomatic relief. 4
• For refractory meibomian gland dysfunction, oral doxycycline or minocycline daily with tapering after clinical improvement is effective. 4
• Alternative oral antibiotics include erythromycin or azithromycin, particularly for women of childbearing age and children. 4
• Treatment can be intermittently discontinued and reinstated based on symptom severity. 4

Contact Lens-Related Keratoconjunctivitis

• Immediately discontinue contact lens wear until the cornea returns to normal. 4
• A brief 1-2 week course of topical corticosteroids may be prescribed for mild cases, with longer-term topical cyclosporine 0.05%. 4
• Review contact lens fit, type, and care regimen at follow-up, considering daily disposable lenses or high oxygen-permeable materials. 4

Neuropathic Ocular Pain

Peripheral Neuropathic Pain

• For peripheral neuropathic corneal pain, start with topical loteprednol 0.5% gel or suspension four times daily for 2 weeks, then twice daily for 2 weeks, then once daily over 6-12 weeks. 4
• Loteprednol has lower rates of increased intraocular pressure and contains minimal neurotoxic preservative (0.003% benzalkonium chloride). 4
• Add topical nerve regenerative therapies like autologous serum tears for additional benefit. 4
• Steroid-sparing agents include topical cyclosporine A 0.05% two to four times daily or tacrolimus 0.03% three times daily. 4

Central Neuropathic Pain

• For central neuropathic pain (symptoms outweighing signs, pain persisting despite treatment), oral neuromodulators are required, with pregabalin as first-line therapy. 4, 5
• Start pregabalin at the lowest dose and titrate slowly; allow 3-4 months at therapeutic dose to assess pain reduction. 4, 5
• Alternative first-line option is gabapentin, though it requires more dose adjustment. 5
• Second-line options include duloxetine (SNRI), with caution in renal impairment. 5
• Topical lidocaine 5% patches can be added for localized neuropathic pain with minimal systemic effects. 5

Adjunctive Therapies for Neuropathic Pain

• Self-retained cryopreserved amniotic membrane (CAM) provides rapid symptomatic relief through anti-inflammatory and neurotrophic effects. 4
• For severe hyperalgesia where patients cannot tolerate the polycarbonate ring, place CAM into bandage contact lenses. 4
• Scleral lenses or PROSE devices decrease light sensitivity and discomfort in 92% of patients by shielding corneal nociceptors from environmental stimuli. 4
• Consider periorbital botulinum toxin A injections for patients with light sensitivity and headache. 4

Inflammatory Conditions

Allergic Conjunctivitis

• Mast-cell stabilizing agents and topical corticosteroids provide relief, but baseline and periodic intraocular pressure monitoring is mandatory when using steroids. 4
• Treat underlying meibomian gland dysfunction with warm compresses, lid massage, and oral doxycycline or azithromycin. 4

Rosacea Conjunctivitis

• Treatment includes eyelid hygiene, warm compresses, systemic tetracyclines, topical corticosteroids and cyclosporine, and topical metronidazole. 4

Post-Surgical and Traumatic Pain

Bacterial Keratitis Prevention

• For corneal abrasions, especially in contact lens wearers, topical fluoroquinolone antibiotics started within 24 hours may prevent ulceration. 4
• Avoid pressure patching in contact lens wearers due to higher risk of secondary infectious keratitis. 4
• Cycloplegic agents decrease pain from inflammation and prevent synechiae formation when substantial anterior chamber inflammation is present. 4

Post-Cataract Surgery Pain

• Topical NSAIDs (nepafenac 0.1%, ketorolac, bromfenac, or diclofenac) reduce postoperative pain and inflammation. 6
• NSAIDs prevent prostaglandin synthesis via cyclooxygenase inhibition and help prevent cystoid macular edema. 6

Critical Pitfalls to Avoid

• Never use topical corticosteroids without monitoring intraocular pressure and evaluating for cataract formation, as prolonged use increases both risks. 4
• Avoid placing punctal plugs in patients with concurrent ocular allergies, as this increases allergen contact time and worsens inflammation. 4
• Do not use two topical beta-adrenergic blocking agents concomitantly for glaucoma treatment. 1
• In patients with severe hyperalgesia, even low concentrations of benzalkonium chloride preservative are not tolerated; use preservative-free formulations. 4
• Recognize that neuropathic ocular pain requires 3-4 months at therapeutic neuromodulator doses before expecting pain reduction—set patient expectations early. 4