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 corneal neuropathic pain, use topical nerve regenerative therapies as first-line treatment, specifically autologous serum tears. 1

• Anti-inflammatory therapy with topical loteprednol is recommended as first-line adjunctive treatment. 1

• Consider self-retained or cryopreserved amniotic membrane (CAM) for rapid symptomatic relief in refractory cases with severe hyperalgesia. 1

• Therapeutic bandage contact lenses or scleral lenses (PROSE) may provide immediate relief by shielding corneal nociceptors from environmental stimuli, though infection risk limits long-term use. 1

Central Neuropathic Pain

For central neuropathic pain or cases with systemic comorbidities, initiate oral neuromodulators as first-line systemic therapy. 1

• Tricyclic antidepressants (TCAs): Start nortriptyline 10-25 mg at bedtime, increase every 3-7 days to 25-100 mg as tolerated (preferred over amitriptyline due to fewer side effects). 1

• Anticonvulsants: Gabapentin or pregabalin are alternatives; carbamazepine 200 mg at night, gradually increased by 200 mg every 7 days to 400-1200 mg divided doses for trigeminal neuralgia-type pain. 1

• Other options include duloxetine, amitriptyline, nortriptyline, or low-dose naltrexone, used alone or in combination. 1

Critical Timing Consideration

All neuromodulators require 3-4 months at therapeutic dose to achieve pain reduction—set expectations early and encourage treatment continuation despite lack of immediate relief. 1

Adjunctive Strategies for Specific Symptoms

• For photophobia and headache: Consider 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-Related Pain

Address underlying tear deficiency and inflammation systematically. 1

• Treat aqueous tear deficiency with preservative-free lubricants and consider punctal plugs after initial anti-inflammatory therapy. 1

• Manage meibomian gland dysfunction with warm compresses, lid massage, and consider oral doxycycline or azithromycin. 1

• Topical cyclosporine 0.05% or lifitegrast 5% for chronic inflammatory conditions. 1

Multidisciplinary Approach for Chronic Pain

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

• Address concomitant anxiety, depression, and mood disorders that commonly accompany chronic ocular pain. 1

• Consider complementary therapies: acupuncture, cognitive behavioral therapy, or hypnosis as adjuncts. 1

Common Pitfalls to Avoid

• Do not dismiss symptoms that outweigh clinical signs—this pattern strongly suggests neuropathic pain rather than inadequate treatment of surface disease. 1

• Avoid preservative-containing formulations in severe hyperalgesia—use preservative-free preparations or compounded methylprednisolone 1%. 1

• Do not expect immediate pain relief with neuromodulators—failure to set appropriate expectations leads to premature treatment discontinuation. 1

• Recognize that ocular surface abnormalities can coexist with neuropathic pain—treat both components simultaneously. 1