Why should topical anesthetics never be dispensed for home use?

Repeated topical anesthetic use can cause anesthetic keratopathy with epithelial breakdown, stromal melt, ring infiltrates, and permanent scarring. Because pain is masked while damage progresses, these drops are for in-office use only.

How should an oral analgesic regimen be chosen for ocular pain?

Systemic NSAIDs are often preferred for inflammatory ocular pain unless contraindicated, in which case acetaminophen is safer. Oral analgesics should be used as adjuncts to targeted ocular therapy, not as a substitute for treating the cause.

When is a bandage contact lens contraindicated?

Avoid bandage contact lenses in active or suspected infectious keratitis or ulcers of uncertain cause. Reserve them for clean traumatic or post-surgical epithelial defects with antibiotic coverage and close follow-up.

What should patients be told to watch for after a painful eye injury?

Give clear return precautions. Worsening pain, reduced vision, increasing photophobia, discharge, or persistent foreign body sensation should prompt urgent reassessment for infection, retained material, or delayed healing.

Ocular Pain Management Medications

Topical and systemic options for common eye pain presentations

Ocular Pain Control: Safe, Stepwise Approaches

Topical anesthetics are in-office only

Proparacaine and tetracaine provide excellent in-office analgesia, but repeated use is toxic to the corneal epithelium and corneal nerves. Unsupervised home use can rapidly lead to epithelial breakdown, ring infiltrates, neurotrophic ulcers, and non-healing corneal melts.

Topical anesthetics should never be prescribed or dispensed for home use. Outpatient pain control should rely on safer strategies such as surface protection, cycloplegia for ciliary spasm, topical NSAIDs when appropriate, and systemic analgesics.

Treat ciliary spasm with cycloplegia

For corneal abrasions, foreign bodies, and anterior uveitis, much of the deep aching pain is driven by ciliary muscle spasm. Cycloplegics reduce this spasm by relaxing the ciliary body and dilating the pupil. This often provides more meaningful relief for this pain pattern than oral analgesics alone. Agent selection and dosing should match the diagnosis and severity, and cycloplegia is most effective when paired with treatment of the underlying cause.

Bandage contact lenses for epithelial defects

For large or highly symptomatic epithelial defects, a silicone hydrogel bandage contact lens can protect exposed nerve endings and reduce mechanical trauma from blinking. This can provide rapid comfort and support re-epithelialization. When a bandage lens is used, prophylactic topical antibiotic coverage is commonly recommended, and close follow-up is essential to confirm healing and rule out infection.

Set expectations and monitor for red flags

Pain control should not obscure diagnosis. Worsening pain, pain out of proportion to findings, reduced vision, increasing photophobia, or a new infiltrate should prompt re-evaluation to rule out infectious keratitis, uveitis escalation, or retained foreign material. Clear return precautions and short-interval follow-up help keep pain control safe.

Ocular Pain Medications

Brand	Generic	Dosing	Amount	Ages	Pregnancy	Mechanism
Alcaine Generic	proparacaine 0.5%	prn	15mL	NA	NA	Sodium channel blocker
Tylenol #3 GenericPO	acetaminophen 300mgcodeine 30mg	q4-6h	single tablet	>18 years	C	analgesicnarcotic (Sch.III)
Ultracet GenericPO	acetaminophen 325mgtramadol 37.5mg	q4-6h(max 8 tabs/d)	single tablet	>12 years	C	analgesicnarcotic (Sch.IV)
Ultram GenericPO	tramadol	q4-6h(max 400mg/d)	50mg	>18 years	C	narcotic (Sch.IV)
Vicodin GenericPO	acetaminophen 300mghydrocodone 5mg	q4-6h(max 12 tabs/d)	single tablet	NA	C	narcotic (Sch.II)

Ocular Pain Management FAQs

Why should topical anesthetics never be dispensed for home use?: Repeated use of topical anesthetics is directly toxic to the corneal epithelium and corneal nerves. Ongoing exposure can cause anesthetic keratopathy with epithelial breakdown, stromal melting, ring infiltrates, and permanent scarring. Because the medication masks pain while damage progresses, patients may present late with severe disease. For that reason, topical anesthetics are for supervised in-office use only. Outpatient pain control should use safer options such as cycloplegia, surface protection, topical NSAIDs when appropriate, and systemic analgesics.
How should an oral analgesic regimen be chosen for ocular pain?: For inflammatory pain (for example from abrasions, scleritis, or uveitis), systemic NSAIDs are often effective because they address the prostaglandin-mediated component of pain. If NSAIDs are contraindicated due to ulcer history, kidney disease, anticoagulation, or other risk factors, acetaminophen may be safer. Oral analgesics work best as adjuncts to targeted ocular therapy, such as cycloplegia for ciliary spasm, surface protection, and appropriate anti-inflammatory or antimicrobial treatment.
When is a bandage contact lens contraindicated?: A bandage lens can increase infection risk if the cornea is already contaminated or if an ulcer is present. It is contraindicated in active or suspected microbial keratitis, fungal disease, or any ulcer of uncertain etiology. In those cases, prioritize appropriate antimicrobial therapy and close monitoring. Bandage lenses are best reserved for clean traumatic abrasions, post-surgical defects, or recurrent erosions with appropriate antibiotic coverage and follow-up.
What should patients be told to watch for after a painful eye injury?: Patients should return urgently for worsening pain, reduced vision, increasing redness, increasing photophobia, new discharge, or a persistent foreign body sensation. These can suggest infection, a retained foreign body, worsening inflammation, or delayed healing. Short-interval follow-up is important for larger abrasions, bandage lens use, or any case where symptoms are not improving as expected.