Ocular Neuropathic Pain (Corneal Neuropathy) |

Ocular Neuropathic Pain (Corneal Neuropathy)

Pain

Pain is an unpleasant sensation we feel sometime to serve a protective purpose to an insult. Most of us, the pain is appropriate to the magnitude of the stimulus. However, there are two over pathological situations that can affect this Insult/Pain relationship. If the pain felt is less than the insult, this is called hypoesthesia. If the pain felt is more than the insult, this is called hyperesthesia. One extreme of the latter is the pain happening without or with minimal stimulation which is called neuralgia which is our subject here.

 

This article is copied with modifications from the EyeWiki. http://eyewiki.aao.org/Ocular_Neuropathic_Pain

 

DISEASE ENTITY

Definition

Ocular neuropathic pain, also referred to as corneal neuropathic pain, is a condition where corneal pain is seen in response to normally non-painful stimuli. This results from repeated direct damage to corneal nerves. Aberrant regeneration with upregulation of nociceptors responsible for processing of painful stimuli leads to hyper-responsivity and increased perception of pain in response to even normally unpainful stimuli. The distorted neuronal excitability which persists even after the tissue has healed is the basis of symptoms of self –sustained chronic corneal pain persisting even in the absence of stimuli and clinical signs – the so called corneal “pain without stain” or “phantom cornea’.1-3 This condition is the ocular analogue of systemic neuropathic pain, complex regional pain syndrome or reflex sympathetic dystrophy (RDS). Ocular or corneal neuropathic pain, corneal neuropathy, corneal neuralgia, kertaoneuralgia and corneal allodynia are all terms that are used to describe the same disease entity.

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Figure 1: Persistent injury to the corneal nerves can lead to permanent modulation of pain pathways resulting in neuropathic pain.  Credit: Neuropathic ocular pain: an important yet under evaluated feature of dry eye. Galor A. et al. Eye 2015

Clinical Impact

Corneal neuropathic pain negatively impacts the quality of life of patients. The unpleasant and often severe sensation of pain, light sensitivity, irritation results in impaired functioning and inability to perform activities of daily living; including reading, driving and working. The impact on physical and social functioning can be debilitating. This condition is being increasingly recognized in patients with chronic dry eye syndrome who don’t seem to respond to conventional dry eye treatment and whose severity of symptoms seem disproportionate to clinical examination. It is a particularly challenging condition in post-refractive surgery patients who suffer from chronic intractable pain. Figure 1.  Corneal pain is also considered as a part of the complex pain syndrome and can be associated with systemic pain syndromes.4-6 Associated symptoms of anxiety and depression also dramatically affect quality of life and in extreme cases can even lead to induction of suicidal thoughts.7-11 Due to relatively recent recognition of the problem, poorly understood underlying mechanisms and no signs on slit lamp examination, these symptoms of pain are often unfortunately ignored by ophthalmologists.

CAUSES OF CORNEAL NEUROPATHIC PAIN

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Figure 2: Causes of Corneal Neuropathic Pain

Triggers that lead to corneal nerve damage result in corneal neuropathy. Damage to nerves during refractive surgeries, ocular surface diseases such as chronic dry eye disease, recurrent corneal erosions, corneal neuropathic infections such as herpetic simplex and zoster, systemic neuropathic conditions such as diabetes, exposure to topical and systemic drugs, radiation keratopathy and chemotherapy.11,12 Figure 2. 

PATHOPHYSIOLOGY

Corneal Neurobiology

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Figure 3: Anatomy of corneal nerves. (a)Schematic representation of the human corneal epithelial innervation showing stromal nerves, subbasal nerve plexus and intra epithelial nerve terminals. (b) A subepithelial nerve fiber (short arrows) in a human cornea penetrates (circle) Bowman’s layer and the epithelial basal lamina and runs in a radial fashin in the subbasal layer. (c) In vivo confocal microscopy showing the central portion of the human subbasal nerve plexus. Credit: The TFOS International Workshop on Contact Lens Discomfort: Report of the Subcommittee on Neurobiology Invest. Ophthalmol. Vis. Sci.. 2013.

Anatomy of Corneal Nerves

The human cornea is one of the most densely innervated tissues. The density of central corneal nerve endings is estimated to be around 7000 nerve terminals per square millimeter. The corneal density of nociceptors in nerve endings is about 300-600 times that of skin and 20-40 times that of tooth pulp. The corneal peripheral sensory nerves are derived from the ophthalmic division of the trigeminal nerves. These nerve endings are initially myelinated. They penetrate the corneal epithelium and Bowman’s layer in a radial fashion 1mm from the corneo – scleral limbus and lose myelination at the site of penetration. After penetration, majority of the nerves turn 90 degrees and run parallel to the epithelial surface in the subbasal layer forming the corneal subbasal corneal nerve plexus. These subbasal nerves run towards the corneal center in a clockwise centripetal pattern. Some of the nerves terminate as free nerve endings.13 Figure 3.

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Figure 4: Physiology of corneal nerves. Schematic representation of the corneal nociceptors and an activated nociceptor. Credit: The Corneal Pain System. Part I: The Missing Piece of the Dry Eye Puzzle. Rosenthal and Borsook. The Ocular Surface, 2012.

Physiology of Corneal Nerves

The subbasal nerve plexus contains both – unmyelinated (80%; C fibers) and myelinated nerve fibers (20%; A-d fibers). The bulbous nerve endings contain the nociceptors. The nociceptors are functionally heterogenous and are classified based on the type of the stimuli they respond to. Polymodal nociceptors (70%, majorly C unmyelinated fibers) respond to a large variety of stimuli including heat, mechanical, endogenous and exogenous inflammatory stimuli. The other nociceptors are mechanoreceptors and cold receptors. This nociceptive system responds to various stimuli at the ocular surface and project to the central nervous system, and helps to sustain ocular surface health.13-15 Figure 4.

Corneal Pain Pathway

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Figure 5: Major ascending brain pathways for trigeminal sensory fibers that supply the eye. Sensory fibers within the TG project centrally to two spatially discrete regions of the trigeminal brainstem complex, the trigeminal subnucleus interpolaris/caudalis transition region (Vi/Vc) and the caudalis/upper cervical cord junction (Vc/C1). Second-order ocular neurons in Vi/Vc and Vc/C1 project to brain regions that mediate eyeblink (facial motor nucleus, VII), lacrimation (superior salivatory nucleus, SSN), and cardiovascular reflexes (nucleus tractus solitarius, NTS). Projections to higher centers such as the periaqueductal gray (PAG), PBA (PB), lateral hypothalamus (LH), posterior hypothalamus (PH), and amygdala (Am) contribute to the affective and modulatory aspects of ocular pain, while projections to posterior thalamus (posterior nuclear group, Po; ventral posteromedial nucleus, VPM) and insular cortex (Ins) mediate sensory-discriminative aspects. Credit: The TFOS International Workshop on Contact Lens Discomfort: Report of the Subcommittee on Neurobiology. Invest. Ophthalmol. Vis. Sci.. 2013.

Acute nociceptive pain pathway

Initially, in the presence of a noxious stimulus, the nociceptors get activated. Transduction mechanism at the nociceptors coverts the external, often mechanical stimulus into electrical impulses along the trigeminal nerve endings. These impulses are then transmitted along the corneal pain pathway – i.e. the trigeminal brainstem complex, trigeminal subnucleus interpolaris/caudalis transition region, upper cervical cord junction and posterior thalamus. These inputs are then processed in the corneal pain region of the cerebral cortex. Figure 5. This perception of acute pain is a protective mechanism.16-18 However with repeated injury this pain pathway becomes maladaptive and loses the protective mechanism and develops into non –protective neuropathic pain. The processes involved are peripheral and central sensitization. Figure 6.

Peripheral Sensitization

Peripheral sensitization is the adaptation of the peripheral pain system to repeated injurious stimuli. Persistent damage and inflammation results in transition from acute nociceptive pain to chronic neuropathic pain.19,20 Severe (often surgical – such as keratorefractive surgery) or repeated injury induces tissue inflammatory response. Pro-inflammaory mediators such as prostaglandins, cytokines and neuropeptides are released. These neuropeptides induce nerve regeneration. Unregulated and ineffective nerve sprouting at the ends of the injured nerve stumps leads to formation of traumatic neuromas. Formation of neuromas further causes sustained inflammation leading to a vicious cycle. Upregulation of ion channels, modification of intrinsic membrane potentials and lowering of the firing threshold makes the nociceptors abnormally hypersensitive to mechanical and chemical stimuli. This hypersensitivity results in aberrant firing thus generating ectopic nerve stimuli. The unregulated generation of ectopic stimuli even in the presence of sub-threshold stimuli is known as peripheral sensitization.21 Figure 6.

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Figure 6: (a)Normal nociceptor response to a noxious stimulus (b) Neuroplasticity in the first-order neuron (peripheral sensitization). (c) Neuroplasticity in the second-order neuron (central sensitization).  Credit: Neuropathic ocular pain: an important yet under evaluated feature of dry eye. Galor A. etal. Eye 2015

Central Sensitization

In addition to the modulation at the level of nociceptors in the presynaptic trigeminal nerve endings, persistent inflammation and nerve damage also act post synaptically in the spinal cord causing direct depolarization along the central pain pathway.22-24 These changes occurring in the CNS in response to repeated nerve stimulation is known as central sensitization. Upregulation of excitatory neurotransmitters, mainly NMDA and inhibition of inhibitory neurotransmitters is also seen. This causes more rapid response to similar stimulus in the future – known as neuronal plasticity.25 This amplification of the neuronal hypersensitivity becomes permanent and persists despite removal of the initial stimulus and apparent healing of the injured tissue resulting in neuropathic pain. This perpetuates pain and dysesthesia even in response to stimuli which are normally non-painful. This is responsible for the “pain without stain” or phantom cornea.2,3,11

CLINICAL FEATURES

Symptoms

Patients generally present with corneal pain of varying severity. Other symptoms are the dry eye like symptoms – foreign body sensation, burning and reflex tearing.26 Also severe photosensitivity – photoallodynia, allodynia and dysesthesias can be seen. Focal facial dystonia and blepharospasms may also be noted. Corneal neuropathy has been shown to be associated with other chronic pain syndromes as well and patients often complain of non-ocular pain. Headaches often migraine type are reported. Additionally, these patients frequently have symptoms of anxiety, depression and apathy. 1,4-6,8,10, 23,27-28

Signs

No clinical findings are generally seen on slit lamp examination. The ocular surface appears healthy. However neuropathic pain may be a component of dry eye syndrome. In such cases surface staining, abnormalities on osmolarity testing and other signs of dry eye and surface disease may be present.9

Diagnosis

Identification of cause

Identification of the inciting insult is important. History of refractive surgery, ocular surface diseases, infections, systemic disorders, radiation exposure and topical and systemic drugs must be elicited.

Quantification of pain

Ocular Pain Assessment Survey (OPAS) is used to quantify pain and impact on quality of life. Other dry eye questionnaires like OSDI may be used, but are not specific for pain.29 Figure 7.

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Figure 7: Ocular Pain Assessment Survey. Credit: Validity and Reliability of a Novel Ocular Pain Assessment Survey (OPAS) in Quantifying and Monitoring Corneal and Ocular Surface Pain . Qazi Y etal. Ophthalmology. 2016

Assessment of ocular surface health and function

Ocular surface health is assessed by Slit lamp examination, use of vital stains, Schirmer’s test, tear break up time, tear osmolarity and tear proteomics. Function of corneal nerves can be assessed using corneal esthesiometry. Both contact (Cochet-Bonnet) and non-contact (Belmonte) esthesiometry is used.9

Differentiating between peripheral and central neuropathic pain

Proparacaine administration helps to differentiate whether neuropathy is peripheral only with sensitization at the level of corneal nociceptors or has progressed to central sensitization. Complete relief of pain in response to proparacaine represents purely peripheral pain however partial relief or no relief at all indicated progression to central sensitization.9 Incomplete response to surface lubrication also indicates central component of pain.30

In vivo confocal microscopy

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Figure 8. IVCM images at the level of the corneal subbasal nerve plexus. A. Normal corneal subbasal nerve plexus. B. Nerve tracings using Neuron J to quantify the density C. IVCM images showing corneal neuropathy. Note the decrease in length and number of nerves, increased tortuosity, reflectivity, beading and formation of neuromas. D. IVCM image showing post-treatment findings of the patient shown at panel C showing improvement in the plexus.
Credit:  Autologous Serum Tears for Treatment of Photoallodynia in Patients with Corneal Neuropathy: Efficacy and Evaluation with In Vivo Confocal Microscopy. Aggarwal S.
Ocul Surf. 2015

In vivo confocal microscopy is a sophisticated techniques which enables in vivo, ultra-high resolution quasi-histological evaluation of the corneal ultrastructure. It is a very useful for diagnosis of corneal neuropathy as it provides direct evidence of nerve injury and allows both qualitative and quantitative measurement.31,32 IVCM shows decreased density of corneal subbasal plexus. Increased hyper-reflectivity, tortuosity, formation of beading and neuromas is also seen.7 Figure 8. Corneal epithelial changes including decreased superficial and epithelial cell densities with increased superficial cell size are seen. In addition, increased of corneal dendritic cells in the subbasal cells provide evidence of inflammation and immune activation.27

TREATMENT

Principles and considerations in management of neuropathic pain

  • Most important consideration is individualized management of neuropathic pain. Every patient needs to be graded according to etiology of corneal neuropathy and severity of symptoms. Focus on restoring the ocular surface health – by preventing further insults to the corneal nerves and decreasing ocular surface inflammation is an important starting point.
  • Identification of the stage of the disease process, i.e. whether neuronal maladaptation and central sensitization has started. Neuro-regenerative strategies help in reversing damage to corneal nerve plexus. Local ocular surface treatment is generally insufficient for patients with central sensitization. More invasive central pain pathway modulation is needed if central sensitization has occurred.33
  • Generally a multimodal therapy is appropriate with a focus of both ocular surface and nociceptor modulation. Step wise therapy with escalation depending on treatment response is used. Multi-specialty approach is needed as ocular neuropathic pain has been shown to be a part of complex pain syndromes and frequently requires inputs from pain specialists, neurologists and psychiatrists.

Management Options

Ocular surface treatment

  • Eye lubrication and treatment of dry eye – like symptoms: Artificial tears are used to prevent surface dryness and provide symptomatic relief. By decreasing the hyper-osmolarity of tears, over-stimulation of the nociceptors is stopped. Tears, ointments and gels are all used depending on patient tolerance. If used more than 4 times, preservative free tears are recommended. Punctal plugs to increase the tear lake are also useful.
  • Topical and systemic antibiotics to treat blepharitis are often used. Systemic fish oil or flax seed oil to treat evaporative component of dry eye disease has also been used.
  • Scleral lenses Scleral lenses, specifically prosthetic replacement of the ocular surface ecosystem (PROSE) has been shown to be effective in treatment of post LASIK corneal neuralgia. The PROSE devices are made of rigid gas permeable lenses, are custom designed and provide fluid ventilation to the cornea.34 Figure 9.

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  • Figure 9: Boston Sight PROSE Device Image Credit: Boston Sight

Anti-inflammatory therapies

  • Steroids: Short courses of topical steroids have been shown to be useful to decrease surface inflammation. This works both to stop the vicious cycle of inflammation and nerve damage and also provides symptomatic relief. Generally these agents are tapered and discontinued once the inflammation is controlled to prevent formation of cataracts and increased intraocular pressure. Steroids with decreased ocular side effects like fluorometholone and loteprednol are preferred.
  • Non-steroidal anti-inflammatory therapies: Topical cyclosporine 0.5% has been shown to decrease the surface inflammation. Also a new drug –lifitegrast has been shown to decrease surface inflammation. These agents modulate T cell mediated inflammation.

Neuro-regenerative therapy

Autologous serum tears – These therapies target the underlying pathophysiology of aberrant nerve regeneration subsequent to repeated injury in neuropathic pain. Various neurotrophic growth factors and epithelial growth factors such as the nerve growth factor (NGF), insulin-like growth factor-1, transforming growth factor β, fibronectin, substance P and epidermal growth factor, which help in proliferation, differentiation and maintenance ocular surface health, are present in high concentrations in serum tears.35,36 NGF is present in high concentrations in serum compared to tears and plays an important role in nerve regeneration and restoration of function of nerves.37-41 Serum tears are also effective in dry eye and neurotrophic conditions of the cornea.42-46 Figure 10.

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Figure 10: Results of a study of effect on autologous serum tear use in corneal neuropathy. IVCM images obtained at the level of the corneal subbasal nerve plexus demonstrate the improvement in the nerve density and morphology following treatment with autologous serum tears. A, C, E. Images at baseline showing increased reflectivity and tortuosity of nerves with presence of beading and neuromas. B, D, F. IVCM images post-treatment corresponding to same patients as A, C, E. Images after 3, 6 and 4 months, respectively, showing increased nerve density and decreased reflectivity, tortuosity, beading, and neuromas. Credit:  Autologous Serum Tears for Treatment of Photoallodynia in Patients with Corneal Neuropathy: Efficacy and Evaluation with In Vivo Confocal Microscopy. Aggarwal, S. Ocul Surf. 2015

Systemic analgesics, anti-depressives and anti-psychotics

Studies have shown that patients with neuropathic pain also have non ocular symptoms of discomfort. This disease entity is a part of the systemic complex pain syndrome. The systemic pain intensity correlates with depression and PTSD correlate with the dry eye like symptoms. These patients are treated with tri-cyclic antidepressants, NSAIDS, dronabinol and tramadol. Gabapentin is also used with variable success.9

Central pain modulation

These treatments have shown to be effective in chronic intractable pain with central sensitization.

  • Electrical neurostimulation – These treatments use the principle of pain gating. Direct neuro-stimulation of the large diameter afferent fibers along the corneal pain pathway using percutaneously placed monopolar electrodes. . Specifically, the area of trigeminocervical complex where the nociceptive corneal afferents in the spinal trigeminal tract synapses with the second order neurons in the area of the C1 C2 levels of the cervical cord is targeted. Figure 11. Direct stimulation inhibits the small diameter nociceptor terminals. However, this is technically challenging and can have complications as migration of the lead. Trans Magnetic Stimulation (TMS) has also been recommended for neuropathic pain.

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  • Figure 11: Lateral X-ray view of the deep-brain stimulator electrode array into the trigeminal ganglion via the left foramen ovale.  Adapted from: Electrical Stimulation of the Trigeminal Ganglion and Intrathecal Drug Delivery Systems for the Management of Corneal Neuropathic Pain. Sayegh, RR etal. Cornea. 35(4):576-577, April 2016.
  • Intrathecal infusion of analgesics – Intrathecal infusion of fentanyl and bupivacaine at the cervical cord level has recently shown to have good long term pain relief. Complications include catheter tip granuloma formation.

Other

Vitamin B supplementation has been shown to be effective in herpes, diabetic neuropathy and neuropathic pain. This is because of the analgesic effects and anti-nociceptive effects. Vitamin B 12 topical therapy leads to re-innervation and re-epithelization of the corneal surface. Vitamin 12 acts through the blockade of the cyclooxygenase pathway. It has anti-nociceptive effects by increasing the serotonin levels in different regions of the brain, inhibiting the nociceptive neurons in spinal cord. Decreasing response of thalamic neurons, or by activating opioid receptors.47 Vitamin D supplementation has also been shown to be effective in specific cases.48 Cardiovascular exercise and dietary modification have also been shown to be effective.

Management ofOcular Neuropathic PainWith Vitamin B12 Supplements: A Case Report. 

Shetty R1, Deshpande K, Ghosh A, Sethu S. 

Abstract 

PURPOSE: 

To report the case of a 28-year-old patient with persistent bilateral burning pain and foreign body sensation in both eyes for the past 1 year. The patient showed a poor response to 0.05% cyclosporine eye drops and frequent instillations of artificial tears. Ocular examination showed few superficial punctate epithelial defects, well-positioned laser in situ keratomileusis (performed 5 years ago with symptomless recovery) flaps, and clear interfaces bilaterally, with a tear film breakup time of 7 and 8 seconds in the right and left eyes, respectively. The results of Schirmer tests, confocal microscopy, corneal esthesiometry, and meibography were normal for both eyes. The patient was incidentally diagnosed with vitamin B12 deficiency, with a serum vitamin B12 value of 90 pg/mL (reference range, 236-911 pg/mL), during routine laboratory tests. In view of weak correlation between signs and symptoms, a putative diagnosis of ocular neuropathic pain secondary to vitamin B12 deficiency was made. 

METHODS: 

Case report. 

RESULTS: 

The patient was treated with parenteral vitamin B12, and topical therapy was continued without any changes. The patient experienced dramatic improvement with a decrease in symptoms within 3 weeks of administering vitamin B12 supplements and was symptom-free in the absence of any topical medication 6 months after treatment. 

CONCLUSIONS: 

Vitamin B12 deficiency, although common in India, has not been reported to be associated with ocular symptoms, including pain and mimicking those seen in severe dry eye. Vitamin B12 deficiency should be considered in the differential diagnosis ofocular neuropathic pain and dry eye in patients presenting with recalcitrant ocular neuropathic pain. 

VITAMIN B12 0.2mg 0.4ml CHAUVIN EYE DROPSVITAMIN B12 0.2mg 0.4ml CHAUVIN EYE DROPS 

3400936730182

VITAMIN B12 Chauvin 0.2mg 0.4ml EYE DROPS: The healing collyrium contains vitamin B12 is used for extra healing disorders of the cornea in the treatment. contains: cyanocobalamin, vitamin B12

Description VITAMIN B12 0.2mg 0.4ml CHAUVIN EYE DROPS. This healing collyrium contains vitamin B12. Is used in the booster of cicatrization disorders corneal treatment.
VITAMIN B12 CHAUVIN 0.2 mg / 0.4 ml: eye drops; box of 10 single dose vials of 0.4 ml
Using advice and opinion on VITAMIN B12 0.2mg 0.4ml CHAUVIN EYE DROPS
Pull down the lower eyelid while looking up and place a drop of eye drops between the eyelid and the eyeball (cul-de-sac conjunctival).
A single dose can be treated, if necessary, both eyes.
Usual dose: 1 drop in the affected eye, 3 or 4 times a day.
VITAMIN B12 composition CHAUVIN 0.2mg 0.4ml EYE DROPS, unidose, Cyanocobalamin (vitamin B12) 0.2 mg. Excipients: Purified Water, Sodium Chloride. 10 single dose vials of 0.4 ml

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