What are the treatment options for eye pain?

Treatment of Eye Pain

Treatment of eye pain must be guided by identifying the underlying cause through systematic evaluation, with immediate ophthalmology referral for vision-threatening conditions such as bacterial keratitis, acute angle-closure glaucoma, or orbital cellulitis. 1, 2

Initial Diagnostic Approach

The first critical step is distinguishing between nociceptive (tissue damage) and neuropathic (nerve dysfunction) sources of pain through comprehensive ocular surface examination. 1

Key Diagnostic Maneuvers

• Perform the "anesthetic challenge test" when neuropathic pain is suspected: instill topical anesthetic while pain is present. If pain improves, this suggests nociceptive or peripheral neuropathic pain; if unchanged, suspect central or non-ocular causes. 1

• Assess for vision-threatening conditions first: bacterial keratitis (infiltrate with suppuration), acute angle-closure glaucoma, scleritis, anterior uveitis, and infectious keratitis all require urgent ophthalmology consultation. 1, 2, 3

• Evaluate ocular surface parameters: tear film stability, aqueous tear deficiency, inflammation, epithelial erosions, and meibomian gland dysfunction can all trigger corneal nociceptors. 1

Treatment Based on Etiology

Bacterial Keratitis (Infectious Pain)

For central or severe bacterial keratitis, initiate frequent topical fluoroquinolone monotherapy immediately (loading dose every 5-15 minutes, then hourly). 1

• Single-drug fluoroquinolone therapy (ciprofloxacin 0.3%, ofloxacin 0.3%, or levofloxacin 1.5%) is as effective as fortified combination therapy for most cases. 1

• Add cycloplegic agents (e.g., cyclopentolate, homatropine) to decrease synechiae formation and reduce pain when substantial anterior chamber inflammation is present. 1

• Fortified topical antibiotics should be considered for large and/or visually significant infiltrates, especially with hypopyon present. 1

Neuropathic Ocular Pain (NOP)

Treatment depends critically on whether nerve dysfunction is peripheral versus central. 1

Peripheral Neuropathic Pain

For peripheral neuropathic ocular pain (corneal neuropathic pain), use topical nerve regenerative therapies as first-line treatment. 1

• Autologous serum tears are the preferred topical nerve regenerative therapy. 1

• Self-retained or cryopreserved amniotic membrane (CAM) provides anti-inflammatory, anti-fibrotic, and neurotrophic effects with rapid symptomatic relief. 1

• Topical anti-inflammatory agents: loteprednol is first-line; use preservative-free formulations (compounded methylprednisolone 1%) in patients with severe hyperalgesia who cannot tolerate benzalkonium chloride. 1

• Protective contact lenses or scleral lenses (e.g., PROSE) can shield corneal nociceptors from environmental stimuli, though infection risk limits long-term use. 1

Central Neuropathic Pain

For central neuropathic ocular pain or patients with systemic comorbidities (fibromyalgia, migraine), oral neuromodulators are first-line systemic therapy. 1

First-Line Systemic Agents

• Tricyclic antidepressants (TCAs): Nortriptyline is preferred over amitriptyline due to superior side effect profile. Start 10-25 mg at bedtime, increase every 3-7 days to 25-100 mg at bedtime as tolerated. 1

• Anticonvulsants: Carbamazepine for trigeminal neuralgia-type pain. Start 200 mg at night, increase by 200 mg every 7 days to 400-1200 mg divided in 2-3 doses daily. 1

• Alternative neuromodulators: Pregabalin, gabapentin, duloxetine, amitriptyline, or low-dose naltrexone can be used alone or in combination. 1

Critical Counseling Point

Set expectations early: all neuromodulators require 3-4 months at therapeutic dose to see pain reduction. Encourage continuation despite lack of immediate relief. 1

Adjunctive Therapies for Specific Symptoms

• For photophobia and headache: transcutaneous electrical nerve stimulation devices or periorbital botulinum toxin A injections (migraine-type strategies). 1

• For cutaneous allodynia or postsurgical pain: periocular nerve blocks with corticosteroid plus long-acting sodium channel blocker. 1

Ocular Surface Disease Contributing to Pain

Address underlying ocular surface abnormalities that can trigger or perpetuate pain. 1

• Treat aqueous tear deficiency: preservative-free artificial tears, punctal plugs (after initial anti-inflammatory therapy), cyclosporine 0.05%, or lifitegrast 5%. 1

• Manage meibomian gland dysfunction: warm compresses, lid massage, oral doxycycline or azithromycin, intraductal probing, thermal pulsation devices, or intense pulsed light therapy. 1

• Address blepharitis and demodex: appropriate lid hygiene and targeted antimicrobial therapy. 1

Multidisciplinary Management

Neuropathic ocular pain warrants involvement of ophthalmologists, pain specialists, neurologists, and mental health professionals. 1

• Patients with NOP frequently experience concomitant anxiety, depression, and mood disorders due to chronic pain and corneal nerve connections to emotional processing centers (prefrontal cortex, amygdala, insula). 1

• Complementary therapies including acupuncture, cognitive behavioral therapy, or hypnosis should be considered as adjuncts. 1

Common Pitfalls

• Symptoms outweighing signs is a hallmark of neuropathic ocular pain—do not dismiss patients as having "functional" complaints. 1

• Persistent symptoms despite appropriate treatment of ocular surface disease suggests neuropathic component. 1

• Avoid chronic prophylactic antibiotics for chronic epithelial defects as efficacy is unestablished and resistance may develop. 1

• Do not use pressure patching for contact lens wearers with traumatic abrasion due to higher risk of secondary infectious keratitis. 1