Pain Management and Opioid Prescribing in Primary Eye Care

    • CE credits 3 hours
    • COPE code 68658-PH / 120089
    • Available until Jul 8, 2023

Introduction

Learning Objectives

  • To review the pathophysiology, causes, and assessment of ocular pain
  • To review the nonpharmacological, pharmacological (including opioids), and surgical or procedural therapies for the treatment of ocular pain
  • To review opioid prescribing guidelines and recommendations

CASE

A 22-year-old male presents to your clinic with an exquisitely painful right eye. He is experiencing significant photophobia. Upon initial inspection, conjunctival injection and mucopurulent discharge around the affected eye are present. His visual acuity is hand motion OD and 20/20 OS, full EOM, pupils measure 4 mm dark and 2 mm light OU, with no RAPD. On slit lamp examination you see a stromal infiltrate and epitheliopathy. You recall seeing him two weeks prior—when he only had symptoms of cloudy vision and photophobia, for which you prescribed topical antibiotic therapy. Surprised that his condition has paradoxically worsened, you check his chart and see that he has a history of contact lens use and fibromyalgia. He says he has maxed out the recommended dose of acetaminophen and ibuprofen to no avail, and is requesting “something stronger” urgently.1, 2

Fig 1. Stromal infiltrate and epitheliopathy on slit lamp examination.

Shortly after, you are called to consult on an 82-year-old male patient with marked swelling of the left eye and associated pain described as “sheer agony”. You notice a blister on the patient's nose and ask how he has been feeling lately. He reveals a 4-day history of progressively worsening malaise, headache, and “prickly” sensations around his forehead that compel him to itch and rub constantly, even throughout the night. On physical exam, his right eye is completely normal, but you are unable to perform a full inspection of the left eye due to the swelling.3

You see a few more patients and end the day—the Friday before a long weekend—with your final consult: a 54-year-old female with “excruciating” pain in her right eye. She is unable to open the affected eye and reluctantly discloses that her 5-year-old grandson struck her with a tree branch while they were out gardening. Review of systems is negative, but she discloses a 30-pack/year history of smoking. Visual acuity is 20/100 OD and 20/30 OS, IOP measures 21 mmHg OD and 14 mm Hg OS. Pupillary shape is normal, with no hyphema and negative Seidel's test. You notice an increased uptake on fluorescein staining at the superotemporal aspect of the cornea.4

Fig 2. Fluorecein staining on slit lamp examination.

Quick Question

What is your approach to managing these three patients?

  • Arrange a prescription for a 3-day course of a low-dose opioid (no refills) for all three patients for immediate and effective pain relief, and arrange to see them again for follow-up investigations after the long weekend.
  • Arrange a prescription of antibiotics for all three patients since they are suffering from infectious (or potentially infectious) causes of ocular pain that must be treated urgently.
  • Conduct a thorough clinical evaluation for all three patients and treat the cause of the pain, using a multimodal approach combining nonpharmacological, pharmacological, and procedural therapies.
     
    CORRECT
  • Encourage all three patients to apply artificial tears generously and trial over-the-counter pain medications, reminding them to arrange a follow-up consult in 5–7 days if the pain persists.

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