AOA 2023: Reviewing the anatomy, pathophysiology of eye pain and its role in dry eye

Jacqueline Theis, OD, FAAO, caught up with Optometry Times to tell us all about her presentation titled, "Neurologic 'dry' eye," which she presented at the 2023 AOA Optometry's Meeting in Washington, DC.

Video transcript

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

Hi, my name is Jacqueline Thies and I'm a practicing optometrist in Richmond, Virginia. I practice in a multidisciplinary brain injury clinic. So we have all kinds of disciplines including brain injury, medicine, physical therapy, neuro endocrinology, and then myself providing eye care for patients.

So I gave a presentation at AOA this year about neurologic dry eye and the concept was kind of twofold. So it really review the anatomy and pathophysiology of eye pain and its role in dry eye. But then also to just kind of think about some of those eye pain patients a little bit differently.

So one of the problems that I hate about dry eye is that the symptoms and the signs never match. You have all these patients where they have neurotrophic keratitis where maybe they have a ton of dry eye signs, and you ask them how they feel, and they say they feel fine; and then you have a bunch of patients where they have neuropathic pain, where the eye looks great, but they're in a ton of pain. And so I really reviewed the differences between them, how to be able to diagnose them.

The big take home away from my lecture is that you just really want to look at treating these patients a little bit sooner. So I used to be under the auspice of you know, if the patient feels fine, I'm happy with it. And what we find actually in studies is that as patients get further dry eye symptoms or neuropathic pain, it becomes harder and harder to treat. So if people would have done the treatment options sooner, they might have been more effective than if they wait longer to do the treatment options.

So it's actually better when you're just starting to see neurotrophic signs and you have someone with a little bit of SPK and they don't feel it, that's actually a sign of neurotrophic keratitis, you should be treating it sooner.

And then for the neuropathic pain lecture, a lot of what we talked about is just how to refer somewhere else. So if somebody is getting eye pain, and they have it for long enough, it can become a peripheral pain sensitization and central pain sensitization problem. And when that happens, sometimes no matter what you throw at the eye, it's not going to make the pain better, in which case, you actually have to do a multidisciplinary treatment with them, maybe send them to a pain specialist who can do nerve injections or nerve blocks, or Botox or things like that. So we really review just kind of a really wide scope view on how you can kind of treat eye pain in a very multidisciplinary way.

Well, one fun thing that I don't think people think about enough is actually the proparacaine challenge test that you can do in office because that's so simple. And so if a patient's coming in and they complain of eye pain, like foreign body sensation, and you put proparacaine in that foreign body sensation should go away if they're having no receptive pain. But if you put proparacaine in and they still have the same pain problem, then that tells you that it's already kind of centralized. And so that's actually a neuropathic pain problem, and so you have to treat it differently. And that's just a really easy way in office within seconds to be able to figure out what type of pain or dry eye you're working with.