When managing ocular pain, first determine the cause
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ATLANTA – The most important first step in ocular pain management is determining why it exists, Jessica Steen, OD, said here at SECO.
“You must first diagnose the condition that’s causing the pain and treat it,” she said.
Clinicians must make it clear to patients that, “our goal of treating ocular pain is not to eliminate the pain,” she said. “Our goal is to reduce the pain or discomfort so the patient can function in a normal circumstance,” like going back to work or taking care of the kids. “Restoring functionality is not the same as eliminating the pain.”
Individuals experience pain in different ways and assessment measures are subjective.
When approaching patients with ocular pain, “start simple,” Steen said. “Think about risks and benefits.”
She recommended consulting online.epocrates.com, a free online resource with information on every pharmaceutical product available in the U.S.
Start by conducting a complete history, then determine a diagnosis and document your pain management plan, Steen said. Establish your treatment goals. Have any patients being prescribed an opioid sign an informed consent and treatment consent. Discuss use and abuse as well as risks.
“Be sure the patient understands you’re prescribing to reduce ocular discomfort, but the treatment carries risks,” she said.
Treat for shortest period with lowest effective dose, she added.
Steen recommended starting with non-opioid medications such as over-the-counter NSAIDs or acetaminophen.
“If that does not impact the discomfort, go with a weak narcotic like tramadol or codeine,” she said. “You can also add a medication, such as adding oral acetaminophen to a weak opioid. Also consider adjuvants to enhance analgesics.”
Medications for nausea, depression and anxiety often play a role in chronic pain management, Steen said.
She offered a pain management pearl: Aim to treat on a fixed dose schedule around the clock vs. as needed.
“Don’t create gaps in their pain management,” she said.
On label, patients can be prescribed up to 1,200 mg/day of over-the-counter 200-mg ibuprofen tablets.
“You can go up to 2,400 mg for pain,” Steen said. “If you know the patient has significant underlying inflammation and they are under your care and also that of another provider treating a systemic problem, it’s OK to go with a higher dose, like 800-mg tablets.”
Naproxen sodium is available as immediate and extended release. However, “Acute pain is best managed short term and aggressively. There is no role for prescribing extended release,” she said.
Risks with NSAIDs include bleeding and a decrease in stomach mucous production that can result in ulcers and intestinal perforation, she said. Use caution in patients with a history of stroke or cardiovascular disease.
Topical ocular NSAIDs have the same mechanism, but tend to sting upon instillation, Steen added. The topical she most often uses is ketorolac 0.5% solution.
Acetaminophen reduces pain, but does not impact inflammation, she noted.
“We need to treat the underlying inflammation,” she said.
If choosing opioids, carefully consider a history of substance abuse in the patient or family and beware of polypharmacy. Patients may not offer information on the use of benzodiazepines.
She noted that sleep apnea is a specific risk factor for opioid overdose.
Steen concluded by reminding clinicians to considering using bandage contact lenses for ocular surface pain and cycloplegic agents for intraocular inflammation.
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Steen J. Practical management of ocular pain. Presented at: SECO; Atlanta, Georgia; April 28-May 2, 2021.
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