Best Practices for Management of Acute Ocular Pain

The term “pain” is often used as a catch-all phrase in health care to describe experiences ranging from mildly unpleasant to excruciating. The experience of pain is highly variable between individuals; it cannot be objectively quantified and is deeply affected by emotional, social, and behavioral experiences.^1,2 So, how do we address our patients’ ocular pain while mitigating the risk of adverse events associated with analgesics and ensuring appropriate diagnosis and management of the condition causing severe discomfort—all within an isolated clinical encounter?

These inherent challenges, combined with the short recovery time of many acute anterior segment conditions that cause discomfort, may lead clinicians to avoid the subject of pain management altogether, which may disrupt mood, mental health, sleep, work, and quality of life—even if short term.¹ Treating ocular pain must involve careful risk assessment and consideration of all available options.¹

WHEN IS PAIN MANAGEMENT NECESSARY?

There are a wide variety of anterior and posterior segment conditions associated with ocular discomfort, including ocular surface disease, corneal abrasion, uveitis, and optic neuritis, which range in severity and underlying cause. After identifying and treating the underlying cause of a patient’s ocular pain, management of pain may be necessary with the clear goal of reducing, rather than eliminating, pain to restore functionality.¹

Keep in mind that the experience of pain differs between individuals and that health care professionals may have hidden biases about who should receive pain management. For example, women may have greater sensitivity to acute stimuli and may respond differently to pain medication.³ Ethnic and racial disparities also persist, such that minority individuals are less likely to be prescribed analgesics by providers.⁴

MANAGEMENT OPTIONS

Our options for managing ocular pain include nonpharmacologic treatment, such as bandage contact lenses, topical ocular cycloplegic agents, topical ocular nonsteroidal antiinflammatory agents (NSAIDs), and oral pharmaceutical agents.

For treating patients with acute pain, there are generally two categories of oral medications: non-opioid medications and opioid medications. Non-opioid oral medications include prescription or OTC NSAIDs and acetaminophen.²

NSAIDs are highly effective suppressors of pain and inflammation, but they carry the potential for side effects, including gastrointestinal bleeding, directly related to their mechanism of action through the inhibition of cyclooxygenase.⁵ Acetaminophen is a centrally acting analgesic and antipyretic that does not have antiinflammatory activity. Although it does not increase the risk of bleeding, like NSAIDs, acetaminophen does carry a risk of liver toxicity related to dosage.²

Opioid medications are highly effective at treating acute pain, but patients taking them have the potential to develop serious and life-threatening side effects, including respiratory depression, dependency, misuse, and overdose, even when taken as prescribed.^1,2

For all oral analgesics, the type of medication, dose, and specific-dosing interval (prn dosing is not appropriate) should be selected to minimize the duration of treatment and provide the lowest-effective dose of medication possible to improve function.¹ Before prescribing or recommending any oral analgesic agent for the treatment of severe ocular discomfort, there are additional steps that the provider should take to get an understanding of the patient’s needs and determine the best approach to managing his or her pain (see Before You Prescribe an Oral Analgesic …).

When considering an opioid medication, additional screening, including history of substance use disorder, family history of substance use disorder, childhood trauma, and depression, is required to mitigate medication-related risks, such as addiction, misuse, and overdose.^1,6

Overall risk assessment of potential for behavioral response to an opioid medication is based on a combination of history, clinical findings, and patient observation.¹ Patients with an average risk for potential chronic opioid use, misuse, or abuse usually have objective clinical signs related to localized symptoms of discomfort and a clear willingness to function at a typical level;^1,6 they usually do not have individual or family history of substance abuse, have a history of depression or anxiety disorder, or take benzodiazepines. For additional steps to consider, see Before You Prescribe an Opioid …).

Treatment with opioid medications should only be initiated when the benefits outweigh the risks.¹ In addition, be sure to advise patients that they should not drive a vehicle or operate power equipment while taking opioid medications, should avoid alcohol and sedatives, and should not share medication with friends or family. Any leftover medication should be properly returned to an authorized collector, which may include pharmacies, collection receptacles in local law enforcement offices, or mail-back options.¹

THE BOTTOM LINE

Regardless of preferred treatment, contemporary acute pain management requires a biopsychosocial approach rooted in empathy to ensure validation and management of patient symptoms while minimizing risk of side effects and toxicity.