Diagnosis and Treatment of Ocular Pain: the Ophthalmologist’s Perspective

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Abstract

Purpose of Review

The aim of this review is to help ophthalmologists and other clinicians understand and treat ocular neuropathic pain.

Recent Findings

Advances in the field of neurophysiology of ocular sensations explain why some cases of dry eye may represent a pain syndrome rather than a problem related to tear status. Principles related to management of pain syndromes such as persistent post-operative pain and complex regional pain syndrome are relevant to the care of these patients.

Summary

Specific strategies for the ophthalmologist, including multimodal therapy comprised of local and systemic approaches, can be helpful in the care of patients with problematic ocular pain. Rather than dismiss these syndromes and these patients, ophthalmologists can serve these patients and the profession well by incorporating an understanding of ocular neuropathic pain into their practice and by collaboration in the care of patients with problematic ocular pain.

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Most cited references 15

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TFOS DEWS II pain and sensation report

David A Bereiter, James S Wolffsohn, Fiona Stapleton … (2017)

Pain associated to mechanical and chemical irritation of the eye surface is mediated by trigeminal ganglia mechano- and polymodal nociceptor neurons while cold thermoreceptors detect wetness and reflexly maintain basal tear production and blinking rate. These neurons project into two regions of the trigeminal brain stem nuclear complex: ViVc, activated by changes in the moisture of the ocular surface and VcC1, mediating sensory-discriminative aspects of ocular pain and reflex blinking. ViVc ocular neurons project to brain regions that control lacrimation and spontaneous blinking and to the sensory thalamus. Secretion of the main lacrimal gland is regulated dominantly by autonomic parasympathetic nerves, reflexly activated by eye surface sensory nerves. These also evoke goblet cell secretion through unidentified efferent fibers. Neural pathways involved in the regulation of Meibonian gland secretion or mucins release have not been identified. In dry eye disease, reduced tear secretion leads to inflammation and peripheral nerve damage. Inflammation causes sensitization of polymodal and mechano-nociceptor nerve endings and an abnormal increase in cold thermoreceptor activity, altogether evoking dryness sensations and pain. Long-term inflammation and nerve injury alter gene expression of ion channels and receptors at terminals and cell bodies of trigeminal ganglion and brainstem neurons, changing their excitability, connectivity and impulse firing. Perpetuation of molecular, structural and functional disturbances in ocular sensory pathways ultimately leads to dysestesias and neuropathic pain referred to the eye surface. Pain can be assessed with a variety of questionaires while the status of corneal nerves is evaluated with esthesiometry and with in vivo confocal microscopy.

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Record: found
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Amitriptyline for neuropathic pain in adults

R Moore, Sheena Derry, Dominic Aldington … (2015)

This is an updated version of the original Cochrane review published in Issue 12, 2012. That review considered both fibromyalgia and neuropathic pain, but the effects of amitriptyline for fibromyalgia are now dealt with in a separate review.Amitriptyline is a tricyclic antidepressant that is widely used to treat chronic neuropathic pain (pain due to nerve damage). It is recommended as a first line treatment in many guidelines. Neuropathic pain can be treated with antidepressant drugs in doses below those at which the drugs act as antidepressants.

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Corneal pain without stain: is it real?

Perry Rosenthal, Inna Baran, Deborah S Jacobs (2009)

Clinicians often encounter patients who report corneal pain suggestive of dry eye disease, yet lack equivalent signs. These patients represent a diagnostic and therapeutic challenge that is more easily dismissed than addressed. We review the physiology of pain and the pathophysiological mechanisms of neuropathic corneal pain and speculate on the mechanisms of certain etiopathogenic triggers, such as LASIK, severe dry eye disease, and Sjogren syndrome. Recognizing corneal neuropathic pain as a disease in its own right is the first step toward developing more effective treatments for these severely disabled and presently inadequately served patients.

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Author and article information

Contributors

Deborah S. Jacobs: djacobs@bostonsight.org

Journal

Journal ID (nlm-ta): Curr Ophthalmol Rep

Journal ID (iso-abbrev): Curr Ophthalmol Rep

Title: Current Ophthalmology Reports

Publisher: Springer US (New York )

ISSN (Electronic): 2167-4868

Publication date (Electronic): 2 November 2017

Publication date PMC-release: 2 November 2017

Publication date (Print): 2017

Volume: 5

Issue: 4

Pages: 271-275

Affiliations

[1 ]BostonSight, Needham, MA USA

[2 ]ISNI 000000041936754X, GRID grid.38142.3c, Harvard Medical School, ; Boston, MA USA

[3 ]ISNI 0000 0000 8800 3003, GRID grid.39479.30, Mass Eye & Ear Cornea Service, ; Boston, MA USA

Article

Publisher ID: 152

DOI: 10.1007/s40135-017-0152-1

PMC ID: 5711963

PubMed ID: 29226029

SO-VID: 0db36c98-ed01-47e0-aad9-28fe1edb2c02

License:

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Diagnosis and Treatment of Ocular Pain: the Ophthalmologist’s Perspective

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Abstract

Purpose of Review

Recent Findings

Summary

Related collections

Hematology and Oncology Discovery

Most cited references 15

TFOS DEWS II pain and sensation report

Amitriptyline for neuropathic pain in adults

Corneal pain without stain: is it real?

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