What are the recommended treatments and when to seek medical attention for eye pain?

Eye Pain: Treatment and When to Seek Medical Attention

Immediate Ophthalmology Referral Required

You must seek immediate ophthalmology consultation if any of the following are present: vision changes, severe photophobia, mid-dilated or poorly reactive pupil, elevated intraocular pressure, or severe pain with blurred vision. 1

Vision-Threatening Emergencies Requiring Urgent Evaluation

• Acute angle-closure glaucoma presents with severe eye pain, halos around lights, opaque vision, and a mid-dilated or oval pupil that reacts poorly to light—this requires immediate ophthalmology referral and gonioscopy, as untreated fellow eyes have an 18% risk of blindness 1

• Infectious keratitis (corneal infection) manifests with severe pain, photophobia, and blurred vision—do not initiate any treatment before establishing diagnosis and obtaining immediate ophthalmologic consultation 1

• Orbital cellulitis characterized by periorbital soft tissue swelling, pain, and restricted eye movement requires immediate imaging and treatment 1

• Giant cell arteritis in patients over 60 with jaw claudication, temporal headache, or scalp tenderness demands immediate ESR/CRP measurement and high-dose prednisone before biopsy to prevent permanent vision loss 2

Critical Examination Components You Need

Before determining urgency, the following must be assessed:

• Visual acuity testing as baseline for every patient with eye pain 1

• Pupil examination for reactivity, size, and shape—any irregularity, poor reactivity, or mid-dilation indicates emergency 1

• Intraocular pressure measurement, especially if angle closure is suspected 1

• Fluorescein staining to assess corneal integrity and identify epithelial defects 1

• Slit-lamp biomicroscopy of the anterior segment to evaluate for inflammation, infection, or structural abnormalities 1

Non-Emergent Conditions Requiring Ophthalmology Referral (Within Days)

Bacterial Keratitis

• Central or severe keratitis (deep stromal involvement or infiltrate >2mm) requires loading doses of topical fluoroquinolone every 5-15 minutes followed by hourly applications 3

• Fortified topical antibiotics should be considered for large and/or visually significant corneal infiltrates, especially with hypopyon present 3

• Cycloplegic agents decrease synechiae formation and pain when substantial anterior chamber inflammation is present 3

• Patients should be educated that redness, pain, or increased photophobia developing while wearing contact lenses requires immediate contact with their ophthalmologist 3

Viral Conjunctivitis

• Adenoviral keratoconjunctivitis with marked chemosis, lid swelling, epithelial sloughing, or membranous conjunctivitis benefits from topical corticosteroids to reduce symptoms and scarring, though close follow-up is mandatory 3

• Herpes simplex virus conjunctivitis requires topical ganciclovir 0.15% gel three to five times daily or trifluridine 1% solution five to eight times daily, or oral antivirals (acyclovir 200-400mg five times daily, valacyclovir 500mg two to three times daily, or famciclovir 250mg twice daily) 3

• Patients not treated with corticosteroids should return if symptoms of red eye, pain, or decreased vision persist after 2-3 weeks 3

Conditions Manageable in Primary Care

Dry Eye Syndrome

• Burning and stinging pain can be disproportionate to clinical signs—manage with ocular lubricants and anti-inflammatory treatment 1

• Artificial tears, topical antihistamines, cold compresses, or oral analgesics provide symptomatic relief 3

• Symptoms typically worsen later in the day and are exacerbated by wind, air travel, low humidity, and prolonged visual tasks 1

Neuropathic Ocular Pain (NOP)

This is commonly misdiagnosed because symptoms outweigh clinical signs:

• The anesthetic challenge test helps localize pain: if topical anesthetic improves pain, this suggests nociceptive or peripheral neuropathic component; if pain persists, it suggests central or nonocular cause 3

• For peripheral NOP, use topical nerve regenerative therapies like autologous serum tears 3

• For central component pain or systemic comorbidities (fibromyalgia), use oral neuromodulators: pregabalin, gabapentin, duloxetine, amitriptyline, nortriptyline, or low-dose naltrexone 3

• Set expectations early: all neuromodulators require 3-4 months at therapeutic dose to see pain reduction 3

• Multidisciplinary approach involving ophthalmologists, pain specialists, neurologists, and mental health professionals is warranted, as patients often experience concomitant anxiety, depression, and mood disorders 3

Critical Pitfalls to Avoid

• Never dismiss transient symptoms (brief episodes of pain with halos around lights) as benign—these represent warning episodes before potentially blinding acute angle-closure attacks with 50% risk of acute crisis within 5 years if untreated 1

• Do not delay fellow eye prophylaxis after treating one eye for angle closure 1

• Avoid fluorescein-anesthetic combination drops for tear break-up time assessment, as anesthetic affects test results 3

• Do not initiate treatment before establishing diagnosis in patients with blurred vision, pain, and photophobia 1

• Never use antibiotics for viral conjunctivitis due to potential adverse treatment effects 3

• Avoid topical corticosteroids in herpes simplex virus epithelial infections as they potentiate the infection 3

Contact Lens Wearers: Special Considerations

• Remove contact lenses immediately and consult ophthalmologist if experiencing redness, pain, tearing, increased light sensitivity, blurry vision, discharge, or swelling 3

• Contact lens-related infections carry higher risk and require aggressive management—never delay evaluation 3

• Patients with traumatic abrasion who wear contact lenses should avoid pressure patching and possibly bandage contact lenses due to higher risk of secondary infectious keratitis 3