What are the management and treatment options for myalgia (muscle pain) and dry eyes?

Management of Myalgia and Dry Eyes

When myalgia and dry eyes present together, immediately evaluate for systemic inflammatory diseases—particularly Sjögren syndrome, rheumatoid arthritis, and systemic lupus erythematosus—as joint pain/muscle ache is a recognized nonocular symptom associated with dry eye disease. 1

Initial Diagnostic Approach

The combination of myalgia and dry eyes should trigger a systematic evaluation for underlying systemic conditions:

• Screen for Sjögren syndrome: Look for dry mouth, dental cavities, oral ulcers, fatigue, and joint/muscle pain as these commonly cluster with dry eye 1
• Assess for other connective tissue diseases: Examine hands for joint deformities characteristic of rheumatoid arthritis, Raynaud phenomenon, and splinter hemorrhages 1
• Evaluate skin: Look for scleroderma, facial changes consistent with rosacea, or seborrhea 1
• Review medications: Antihistamines, diuretics, antidepressants, and any drugs with anticholinergic effects can exacerbate both conditions 1, 2

Referral to rheumatology is warranted when systemic inflammatory disease is suspected, as patients with primary Sjögren syndrome or connective tissue diseases require management by an appropriate medical specialist. 1

Dry Eye Management Algorithm

Mild Dry Eye Treatment

Start with environmental modifications and preservative-free artificial tears:

• Eliminate cigarette smoke exposure completely, as it adversely affects the tear film lipid layer 1, 3
• Humidify ambient air and use side shields on spectacles to minimize air draft exposure 1, 3
• Lower computer screens below eye level and schedule breaks every 20 minutes to increase full blinking 1, 3
• Use preservative-free artificial tears when applying more than 4 times daily to avoid ocular surface toxicity 1, 3
• Apply lubricating ointments overnight for longer-lasting protection 1, 3
• Implement eyelid hygiene and warm compresses to improve meibomian gland function 2

Moderate Dry Eye Treatment

Add anti-inflammatory therapy when environmental modifications and artificial tears are insufficient:

• Cyclosporine 0.05%: One drop in each eye twice daily (approximately 12 hours apart) to prevent T-cell activation and inflammatory cytokine production 1, 3

  • Expect 10-mm increase in Schirmer test results at 6 months in 15% of patients 1
  • Ocular burning occurs in 17% of patients but is typically well tolerated 1
  • Requires 3-4 months at therapeutic dose to see pain reduction 1

• Lifitegrast 5%: One drop twice daily (approximately 12 hours apart) for treatment of signs and symptoms of dry eye disease 4

  • Most common adverse reactions (5-25% of patients): instillation-site irritation, dysgeusia, and reduced visual acuity 4
  • Remove contact lenses prior to administration; may reinsert 15 minutes later 4

• Topical corticosteroids: Use for 2-4 weeks maximum to decrease ocular irritation and corneal fluorescein staining 1, 3

  • Extended use beyond 4 weeks risks complications 3

Severe Dry Eye Treatment

Escalate to advanced therapies for refractory cases:

• Punctal plugs or cautery for tear retention after optimizing topical therapy 3
• Autologous serum eye drops (20% concentration) to improve ocular irritation and corneal/conjunctival staining, particularly beneficial in Sjögren syndrome 3, 5
• Oral secretagogues (pilocarpine or cevimeline) to stimulate tear production in Sjögren syndrome patients 1, 3
  • Note: Over 40% of patients experience excessive sweating; 2% withdraw due to side effects 1

Addressing Neuropathic Ocular Pain

If ocular pain persists despite appropriate dry eye treatment and symptoms outweigh observed signs, consider neuropathic ocular pain (NOP):

• Perform the anesthetic challenge test: If pain improves after topical anesthetic, this suggests peripheral neuropathic component; if no improvement, consider central or nonocular causes 1
• For peripheral NOP: Use topical nerve regenerative therapies like autologous serum tears 1
• For central NOP or systemic comorbidities (fibromyalgia, depression, anxiety, migraine): Use oral neuromodulators including pregabalin, gabapentin, duloxetine, amitriptyline, nortriptyline, or low-dose naltrexone 1
• Complementary therapies: Consider acupuncture, cognitive behavioral therapy, or hypnosis for concomitant anxiety and depression 1

Patients with severe ocular pain often have associated psychological and systemic pain conditions including fibromyalgia, depression, anxiety, and migraine, requiring a multidisciplinary approach. 5

Myalgia Management in Context

While the evidence focuses primarily on dry eye management, the presence of myalgia with dry eyes necessitates:

• Immediate rheumatologic evaluation if systemic inflammatory disease is suspected 1
• Oral macrolide or tetracycline antibiotics may address both meibomian gland dysfunction and systemic inflammatory components 2, 3
• Omega-3 or omega-6 fatty acids orally for anti-inflammatory effects 6

Critical Pitfalls to Avoid

• Do not dismiss the myalgia as unrelated—it is a recognized nonocular symptom of dry eye-associated systemic diseases 1
• Avoid indiscriminate corticosteroid use beyond 4 weeks due to complication risks 3
• Do not overlook medication review—many systemic drugs exacerbate dry eye 1, 2
• Recognize treatment resistance: Patients with higher pain intensity are less responsive to standard dry eye treatments (artificial tears, steroids, cyclosporine, punctal occlusion), suggesting neuropathic pain mechanisms 5

Referral Criteria

Refer to ophthalmology immediately for: 1

• Moderate or severe pain
• Lack of response to therapy
• Corneal infiltration or ulceration
• Progressive conjunctival scarring
• Vision loss