CLINICAL

  ANTERIOR

EYE PAIN AND OCULAR ALLERGY

IMPLEMENT THESE TREATMENT PROTOCOLS TO RELIEVE DISCOMFORT

JOSH JOHNSTON, O.D., F.A.A.O.

Q: WHAT ARE THE BEST TREATMENT OPTIONS FOR EYE PAIN?

A: The answer to this question varies depending on the reason for the pain and its severity. To start, I recommend using a topical anesthetic, such as 0.5% proparacaine or tetracaine, in office, so you can determine the pain’s cause without inflicting further patient discomfort. (Using an anesthetic is particularly useful for corneal and conjunctival abrasions that cause photophobia, and, thus, make the exam hard to do.)

For mild ocular surface issues, such as punctate keratitis from an irritant or injury, I prescribe artificial tears to provide relief and promote lubrication.

When I note anterior chamber inflammation, as seen in conditions such as iritis and keratitis, I prescribe a cycloplegic, which provides an analgesic effect, stops the ciliary spasm and stabilizes the blood aqueous barrier.

Inflammation, in general, can be controlled with topical steroids and NSAIDs, which also provide an analgesic effect. In cases of severe ocular inflammation, such as scleritis, I prescribe oral steroids and narcotics, such as Tylenol No. 3, hydrocodone and codeine.

For post-ablation procedures, such as PRK, I prescribe diluted analgesics (three to four drops of proparacaine in a sample bottle of artificial tears) in conjunction with one or more of the topical treatments mentioned above. I may also prescribe OTC oral medications, such as acetaminophen, NSAIDs and ibuprofen.

Pain’s reason and severity dictates treatment.

For severe corneal abrasions and pain from post-surgical procedures, such as PRK and PTK, I use bandage contact lenses and amniotic membranes. I often soak bandage contact lenses in an NSAID for 10 minutes before placing the lens in the eye. This can help increase the residence time of the medication. Amniotic membranes help decrease inflammation and promote regeneration and healing.

Q: WHAT IS YOUR TREATMENT PLAN FOR GIANT PAPILLARY CONJUNCTIVITIS (GPC)?

A: I treat GPC in a staged approach based on its severity. For mild GPC (occasional or mild allergic symptoms with mild contact lens issues), I prescribe lubricating artificial tears to wash away allergens from the ocular surface and help decrease symptoms of ocular dryness. In addition, I prescribe combination antihistamine/mast cell stabilizer drops, which act fast to prevent the allergic reaction from occurring, after a first occurrence.

I instruct my contact lens-wearing patients who present with GPC to discontinue contact lens wear for one to two weeks while using the aforementioned treatments to help normalize their lids and ocular surface. Further, I switch these patients from a multi-purpose contact lens solution to a peroxide-based solution, which includes less preservatives than other contact lens solutions and thus, decreases the likelihood of worsening allergy symptoms. (Patients must be educated on how to use these solutions, as they are caustic until neutralized.)

Classic giant papillary conjunctivitis.
PHOTO COURTESY: Derek Van Veen, O.D., M.S.

For moderate to severe GPC, I prescribe the aforementioned treatment options along with a topical corticosteroid b.i.d. for two weeks to decrease lid and ocular surface inflammation. I also consider increasing the dosage or duration of the topical corticosteroid if the GPC is exceptionally severe.

Once the allergic component has been controlled in a contact lens wearer diagnosed with severe GPC, I discontinue the topical corticosteroid and switch the patient to daily disposable contact lenses. This modality will minimize the build up of lipids, denatured proteins and inflammatory molecules that get recruited from inflammatory mediators trapped in contact lenses. OM

Questions are based on reader responses to an Optometric Management online survey, which closed on Dec. 20.

DR. JOHNSTON practices at Georgia Eye Partners. He focuses on ocular surface disease and has extensive experience in co-managing cataract and refractive surgery patients. Email him at drj@gaeyepartners.com, or visit tinyurl.com/OMcomment to comment.