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Surgeons need to distinguish neuropathic pain, dry eye disease in cataract surgery patients

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WAIKOLOA, Hawaii — Properly distinguishing the symptoms of neuropathic pain from dry eye disease can help reduce pain after cataract surgery, according to a speaker here.

“In these patients with neuropathic pain, there is a marked disparity between signs and symptoms. They complain of spontaneous burning, grittiness or irritation. Many of them have allodynia to wind or light, light-evoked pain and tired eyes. They have chronic dry eye, of course, and poor response to dry eye disease therapy,” Jay S. Pepose, MD, PhD, said at Hawaiian Eye 2019.

Patients with neuropathic pain typically exhibit increased sensitivity to ocular and dermatomal pain stressors and often have overlapping pain conditions such as fibromyalgia or irritable bowel syndrome. Additionally, many have mood disorders such as post-traumatic stress disorder, sleep apnea or sleep disorders, he said.

Aggressive measures to reduce pain and inflammation after cataract surgery can reduce symptoms. Pregabalin or gabapentin can be used in higher-risk patients, he said.

A proparacaine challenge test should be utilized to determine which type of pain a patient is experiencing, Pepose said.

“If they have complete relief of symptoms, I know that they have peripheral sensitization. If it reduces their symptoms somewhat, then they have a mixed combined pain, so both central and peripheral. If they have none at all, then it’s central pain,” he said.

Patients with peripheral pain respond well to neuroregenerative therapies such as autologous serum, amniotic membranes and topical anti-inflammatories. Those with mixed combined pain respond better to systemic pharmacotherapy, as well as complementary therapies such as acupuncture or cardiovascular exercise, he said.

Patients with centralized pain require both systemic pharmacotherapy and possible consultation with a neurologist or pain specialist for transcranial stimulation or other therapies, he said. – by Robert Linnehan

Reference:

Pepose JS. Cataract surgery, neuropathic pain and dry eye: Association, diagnosis and treatment. Presented at: Hawaiian Eye; Jan. 19-25, 2019; Waikoloa, Hawaii.

Disclosure: Pepose reports financial disclosures with AcuFocus, Bausch + Lomb, Johnson & Johnson Vision, Shire, Sun Pharma and TearLab.