Eye Pain

Vignette:

An 83 year old female with history of bullous keratopathy complains of severe left eye pain. She describes the pain as sharp with continual sensation of irritation under her eyelid. She also has a history of glaucoma, cataracts, and is legally blind. She was treated in the past with antibiotics and saline drops without relief. She is currently taking hydrocodone with acetaminophen which decreases the pain to 5/10. She declines surgical intervention and requests symptom management. She is a palliative care patient, not on hospice. What treatments would be recommended for palliation of eye pain in this case?

Discussion:

Bullous keratopathy is a swelling of the cornea due to endothelial damage. It is most commonly seen in older people and can occur after cataract surgery. Pain associated with bullous keratopathy may be secondary to rupture of bullae in the eye exposing corneal nerve endings. Therapy for bullous keratopathy aims to reduce discomfort and/or improve visual acuity. Epithelial edema can often be managed with topical hypertonic agents such as sodium chloride (5%) ointment or drops. Hydrophilic contact lenses, on an extended-wear basis, can also be used to decrease pain associated with epithelial bullae. The hydrophilic extended-wear contact lenses used in combination with 5% hypertonic saline are recommended as a hypertonic reservoir to constantly bathe the cornea. In the presence of low-grade inflammation, topical steroids can be useful in limited fashion, since low-grade anterior uveitis is sometimes associated with chronic corneal edema. However, prolonged use of steroids is not recommended as they can lead to infections. Topical anesthetic eye drops should not be used because their efficacy is reduced after prolonged use and rebound episodic pain occurs prompting more frequent use by the patient. Frequent instillation leads to necrosis of the corneal nerve endings, and this exacerbates ocular pain in a vicious circle leading to further keratitis and damaging epithelial defects and stromal infiltrates. Several surgical procedures are also available to decrease pain in advanced cases. For this patient, saline ointment and contact lenses were sufficient in palliating her eye pain.

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