AAOpt 2024: Managing neuropathic corneal pain

Erin Rueff, OD, PhD, FAAO, discussed her presentation on neuropathic corneal pain at the 2024 American Academy of Optometry meeting in Indianapolis, Indiana. She highlighted that this condition, often mistaken for dry eye, involves the corneal and central nervous systems sending pain signals despite no visible eye injury. Rueff emphasized the importance of recognizing and validating patients' symptoms, using corneal sensitivity testing, and employing a step-wise management approach. She also stressed co-management with psychological professionals to address the psychological impact of chronic pain. Key takeaways include identifying patients through history, effective communication, and considering comprehensive treatment options.

This summary was written by utilizing AI resources.

Video transcript:

Editor's note: The below transcript has been lightly edited for clarity.

Emily Kaiser Maharjan:

Hi everyone. I'm here with Dr Erin Rueff, who is here to discuss her 2024 American Academy of Optometry presentation, "Pain Without Stain: Managing Neuropathic Corneal Pain." So thanks for taking the time to chat today, Dr Rueff, I'm really excited.

Erin Rueff, OD, PhD, FAAO:

Thanks for having me.

Kaiser Maharjan:

Of course. So first, can you tell me more about your presentation on neuropathic corneal pain?

Rueff:

Well I'm going to talk this year in Indianapolis about neuropathic corneal pain. So this is a kind of condition that I think most people think as a sort of subset of dry eye. But these patients, I would argue, actually don't have dry eye. They oftentimes present to our clinic with symptoms that they report as severe dry eye, or that they've been told in the past that they have severe dry eye, but when you look at their eyes under the slit lamp, their eyes look crystal clear. Their lids look healthy. They're using artificial tears a lot, and that's because they've been experiencing these really debilitating symptoms that oftentimes no one's been able to kind of diagnose appropriately or get a good treatment plan going. And what's really happening for these patients is that their corneal nervous system, and for some of them, their central nervous system, is sending their brain a signal that there's pain stimulus in their eye when there isn't one, and for most of these patients, that's because they've had a history of maybe an injury or surgery or another systemic event that caused their nervous system to go out of whack. So my talk is going to talk about how to identify these patients.

What I think is important and interesting about this talk is that I'm actually going to talk about the pathophysiology of the condition. So for a lot of doctors, I think this condition is frustrating, because it can sometimes feel confusing with the patient in the chair. Like, are they malingering? [Do] they maybe have more of a psychiatric issue going on, because, again, their eyes look so good in the microscope. And so I'm actually going to show attendees evidence that shows on a microscopic level that the nervous system and the corneal nerves are injured and not working appropriately. And then, most importantly, give attendees a really easy to follow, kind of step wise approach to how to manage these patients so that they can get relief effectively and in a hopefully timely and efficient manner.

Kaiser Maharjan:

How does corneal sensitivity tie into the neuropathic pain situation?

Rueff:

Yeah, so with these patients, we can kind of think about corneal sensitivity on a spectrum. A lot of times when we talk about neuropathic corneal pain, patients or doctors might also think about the condition or the term neurotrophic keratitis. And those are sort of 2 conditions on either end of a spectrum. Neurotrophic keratitis is when our corneas have been injured so many times that the nervous system just kind of gives up and doesn't tell us that there's injury or a pain stimulus there. On the other end of the spectrum is neuropathic pain, and that's when the cornea appears to be healed. It looks good, but our nerves are still saying, "Hang on, not we're not working right," or something's not right here. And so in patients with neuropathic pain, their corneas are ultra sensitive, and those neurotrophic patients are hypo sensitive, under sensitive. So we'll actually talk in the lecture about corneal sensitivity testing and strategies for identifying or things you can do in office to try to objectively show that these patients are hyper sensitive to normal stimuli.

Kaiser Maharjan:

Of course, and with neuropathic pain, how do you go about having that conversation with patients where you're like, "Yes, your pain is real. This is happening to you. However, it's physiologically not showing up in the same way." How do you manage that conversation?

Rueff:

I think having that conversation for a lot of patients is the most important part. A lot of times, once these patients get in their your chair, they've seen multiple providers, they've tried a lot of different treatments. They might have felt dismissed by other providers. And I found in my practice, like so many things in healthcare, that sometimes just validating a patient's symptoms by saying, "Yeah, you are experiencing this, and it's legit, and here's why, and here's what we can do to move forward," sometimes that conversation is as important than any treatment plan you're going to implement. I should mention too, that we'll talk in the lecture about treatments that we can employ as eye care providers, but a really important factor in managing a lot of these patients is also comanaging with either a psychological professional or even psychiatry to better understand. Sometimes these patients can suffer from almost like a PTSD type of experience or response from having chronic pain or potentially, if the chronic pain was due to a traumatic event. And so, you know, thinking as these patients, not just as a pair of eyeballs, but as a whole person, and thinking about how that pain has influenced their life over a long period of time is really important. So yeah, that empathetic acknowledgement and validation of what they're experiencing is so, so important.

Kaiser Maharjan:

Absolutely, I absolutely agree. So do you have any key takeaways from your talk that you really want to drive home to the optometric community?

Rueff:

Yeah. I mean, I think kind of what we just talked about is that being able to recognize these patients in your chair. I find that I can almost identify these patients by history alone, based on their level of urgency and frustration with not being able to find a meaningful treatment plan, and then being able to communicate to them what's happening and understanding the treatment options that are available and being able to choose the ones that are going to be most beneficial for that patient, while also considering comanagement care as well. So I think those are the major takeaways. But hopefully people who attend will feel more confident with these types of patients. And if you're like me, the first few times I saw patients with this condition where I could confidently say they had this condition, these are the patients that you think about when you're driving home at night, that you think about when you're cooking dinner that maybe a week later you want to almost give them a call and check in with them and see how they're doing, because you could in your gut feel their level of frustration and their mental anguish. So hopefully, this gives eye care providers some confidence in identifying and managing these patients so that we can get them where we all want them to be.

Kaiser Maharjan:

Alright. Well, thank you so much for taking the time to chat with me today about neuropathic corneal pain, Dr Rueff. I've learned a lot, and I'm sure this information will benefit optometrists everywhere. So thank you very much.

Rueff:

Thank you.