Neuropathic Ocular Pain due to Dry Eye Is Associated With Multiple Comorbid Chronic Pain Syndromes

Galor, Anat; Covington, Derek; Levitt, Alexandra E.; McManus, Katherine T.; Seiden, Benjamin; Felix, Elizabeth R.; Kalangara, Jerry P.; Feuer, William J.; Patin, Dennis; Martin, Eden R.; Sarantopoulos, Konstantinos D.; Levitt, Roy C.

doi:10.1016/j.jpain.2015.10.019

Cited by 79 publications

(69 citation statements)

References 67 publications

(87 reference statements)

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“…Table 1 describes some of the characteristics for these two symptom classes. Neuropathic ocular pain due to dry eye can be associated with multiple comorbid chronic pain syndromes 61 . Although neuropathic contributions to DES are more likely to be associated with more severe and/or chronic symptoms, it is not known to what extent mild to moderate DES symptoms can include a neuropathic component.…”

Section: Discussionmentioning

confidence: 99%

The potential role of neuropathic mechanisms in dry eye syndromes

McMonnies

2017

Journal of Optometry

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Dry eye syndromes can involve both nociceptive and neuropathic symptoms. Nociceptive symptoms are the normal physiological responses to noxious stimuli. Neuropathic symptoms are caused by a lesion or disease of the somatosensory nervous system and can be the result of hypersensitisation of peripheral or central corneal and conjunctival somatosensory nerves. For example, inflammation could induce neuroplastic peripheral sensitisation of the ocular surface or lid wiper and exacerbate nociceptive symptoms. Neuropathic symptoms may explain the incommensurate relation between signs and symptoms in some dry eye syndromes although absence of signs of a dry eye syndrome may also be a consequence of inappropriate methods used when examining for them. Involvement of neuropathic mechanisms may also help explain dry eye symptoms which occur in association with reduced corneal sensitivity. This review includes a discussion of the potential for ocular symptoms involving neuropathic mechanisms to contribute to psychosocial problems such as depression, stress, anxiety and sleep disorders as well as for these types of psychosocial problems to contribute to neuropathic mechanisms and dry eye syndromes. Failure to consider the possibility that neuropathic mechanisms can contribute to dry eye syndromes may reduce accuracy of diagnosis and the suitability of treatment provided. Dry eye symptoms in the absence of commensurate evidence of tear dysfunction, and unsatisfactory response to tear dysfunction therapies should prompt consideration of neuropathic mechanisms being involved. Symptoms which persist after local anaesthetic instillation are more likely to be neuropathic in origin. Reducing inflammation may help limit any associated neuroplastic hypersensitivity.

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Section: Discussionmentioning

confidence: 99%

The potential role of neuropathic mechanisms in dry eye syndromes

McMonnies

2017

Journal of Optometry

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“…2 Neuropathic pain can also occur in the cornea, 3–7 the most richly innervated tissue in the body. 8 Neuropathic corneal pain (NCP) remains an ill-defined entity (also termed corneal neuralgia, keratoneuralgia, corneal allodynia or corneal neuropathy), 3–7 and can be perceived as pain, 9 discomfort, 10 aching, 11 photoallodynia, 6 burning, 10 irritation 10 , dryness, 11 and grittiness; 11 symptoms that may overlap with diseases such as dry eye disease (DED). 12 NCP can result from both peripheral nerve injury 5–7, 9 or systemic etiologies, 4,10, 9,13 and owes much of its understanding to advances in the pathophysiology and neurobiology of systemic neuropathic pain.…”

Section: Introductionmentioning

confidence: 99%

Neuropathic Corneal Pain

2017

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Neuropathic pain is caused by a primary lesion or dysfunction of the nervous system and can occur in the cornea. However, neuropathic corneal pain (NCP) is currently an ill-defined disease. Patients with NCP are extremely challenging to manage and evidence-based clinical recommendations for the management of patients with NCP are scarce. The objectives of this review are to provide guidelines for diagnosis and treatment of patients with NCP and to summarize current evidence-based literature in this area. We performed a systematic literature search of all relevant publications between 1966 and 2017. Treatment recommendations are, in part, based on methodologically sound randomized controlled trials (RCTs), demonstrating superiority to placebo or relevant control treatments, and on the consistency of evidence, degree of efficacy, and safety. In addition, the recommendations include our own extensive experience in the management of these patients over the past decade. A comprehensive algorithm, based on clinical evaluation and complementary tests, is presented for diagnosis and subcategorization of patients with NCP. Recommended first-line topical treatments include neuro-regenerative and anti-inflammatory agents, whilst first-line systemic pharmacotherapy includes tricyclic antidepressants and the anticonvulsant. Second line oral treatments recommended include the opioid-antagonist and opiate analgesics. Complementary and alternative treatments, such as cardio-exercise, acupuncture, omega-3 fatty acid, and gluten-free diet, may have additional benefits, as do potential non-invasive and invasive procedures in recalcitrant cases. Medication selection should be tailored on an individual basis, considering side effects, comorbidities, and levels of peripheral and centralized pain. Nevertheless, there is an urgent need for long-term studies and RCTs assessing the efficacy of treatments for NCP.

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“…Indeed, neuropathic ocular pain may represent a central pain disorder, and that shared mechanistic factors which predispose patients to certain forms of dry eye. It is therefore recommended that evaluation and treatment for neuropathic pain should be considered in dry eye patients [16]. Other commonly associated comorbidities in dry eye include sleep disturbances [17], anxiety and depression [18], migraine [14], rheumatological disease and allergies like sinusitis [19].…”

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confidence: 99%

From Volume to Value: Prospects and Pitfalls in Organising Integrated Dry Eye Practice Units

Goh¹,

Korne²,

Tong³

2017

J Clin Exp Ophthalmol

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With the advent of aging populations, chronic multifactorial diseases will dominate and strain existing models of health care. A model of healthcare delivery that emphasizes seamless, integrated, team-based care and remuneration for patient outcomes, have proven advantageous in diseases like diabetes mellitus, compared to systems based on isolated medical services. It is, however, unclear whether major chronic ophthalmic diseases including dry eye are also suitable for this model. Multiple co-morbidities such as depression, anxiety, postmenopausal mood swings, sleep disorders, and chronic neuropathic pain in dry eye greatly and unexpectedly increase its healthcare burden, and also produce high levels of patient and physician frustration. Many patients benefit from counseling, social support, and psychological management, but are frustrated by multiple referrals and inefficiency in care coordination. With the new model, patients may have a seamless transition between care settings, better experience and improved outcomes, and likely attain added value per unit cost.Keywords: Eye diseases; Health policy; Practice guidelines as topic; Primary health care; Quality of health care Rethinking Care for Chronic DiseasesThe trend of medical sub-specialization with the development and proliferation of organ-based or medical technique-based healthcare centers has clearly benefited many generations of people in developed and even developing countries [1]. The advantages of providing highend care are mainly in single, acute problems requiring specialized skills. However, incurable and disabling chronic multi-organ diseases are increasing, due to aging of communities and partly, success of specialized disciplines in management of treatable maladies. We define chronic disease as by WONCA International Classification Committee: a health condition that is long in duration-often with long latency and protracted course, multi-factorial in aetiology, no definite cure, changes gradually over time, heterogeneous in susceptibility" [2], including the lived experience of coping with health disruption and impact on psychological and social function [3].In chronic diseases with multiple comorbidities, health-care disciplines should be integrated and centered on the patient. The "Esther network" [4] and Ed Wagner's chronic disease model [5] are examples of integration across the entire continuum of care, including self and community care, which also cater to the bio psychosocial needs of a person [6]. A study involving 113,452 unique patients evaluated the integration of primary healthcare family practice, internal medicine and geriatric practices, and found superior outcomes in terms of depression screening rates and increased adherence to care, with less emergency visits/admissions [7].The traditional model of healthcare, pivoted around specialized tertiary centers ( Figure 1A), is not optimized for chronic disease care. Traditional healthcare models are largely 'serviced-based' , whereby patients are typically charged for each i...

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Neuropathic Ocular Pain due to Dry Eye Is Associated With Multiple Comorbid Chronic Pain Syndromes

Cited by 79 publications

References 67 publications

The potential role of neuropathic mechanisms in dry eye syndromes

The potential role of neuropathic mechanisms in dry eye syndromes

Neuropathic Corneal Pain

From Volume to Value: Prospects and Pitfalls in Organising Integrated Dry Eye Practice Units

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