How to recognize neuropathic pain in the optometric practice

Leslie Small

CHICAGO – Any optometrist can determine if a patient experiencing ocular pain has neuropathic pain in 4 minutes without special technology, according to Leslie Small, OD, here at the American Academy of Optometry meeting.

Small, of the Bascom Palmer Eye Institute, outlined her diagnostic protocol during the Anterior Segment Section symposium, which was cosponsored by Primary Care Optometry News.

“We start with symptoms, then we look at how those symptoms affect their daily life,” she said, “especially how neuropathic pain affects their emotional life.”

Small said to ask when the pain started, the time course, any treatments that have helped or failed, and if the patient has followed the treatment protocol.

“Look for psychiatric meds,” she said. “Anxiety and depression are correlated with neuropathic pain. And any medications that contribute to dryness.

“Time is short when we’re in the clinic,” Small continued. “We need to standardize our approach.”

She recommended having patients fill out questionnaires, such as the Dry Eye Questionnaire (DEQ) 5 and Ocular Surface Disease Index (OSDI), while in the waiting room.

“The DEQ goes over discomfort, dryness and watering eyes,” Small said, while the OSDI focuses on symptoms and effect on lifestyle and environment.

“Just like you have an exam protocol with your glaucoma patients, you need an exam protocol for dry eye,” she said.

Small will:

--evert the upper and lower lids to look for follicles and papillae;

--squeeze lids to determine meibum quality;

--use InflammaDry (Quidel), if available, to look for inflammatory mediators;

--evaluate corneal sensitivities using dental floss;

--insert fluorescein and evaluate tear production and volume by measuring the tear lake;

--do Schirmer’s testing;

--look for conjunctival chalasis; and

--perform tear break-up time and corneal staining.

“It’s important to grade the severity of staining so you can monitor over time if signs and symptoms improve,” Small said. “Fluorescein doesn’t stay in the conjunctiva; you’ll need lissamine green to do that. Look at the severity and the location.”

Small explained how to perform the proparacaine test.

Ask patients to rate their pain and discomfort or irritation on a scale of zero to 10.

“Insert proparacaine, wait about 20 or 30 seconds, then ask them again,” she said. “Check for comorbidities. If they have a corneal ulcer, they have uveitis and not neuropathic pain.”

Small said this evaluation can be performed in 4 minutes.

“Anyone can incorporate this,” she said. “There’s no extra technology; it’s all in your exam room.”

Small said she breaks it down into sections: before the slit lamp, behind the slit lamp, pain and other.

“We’re not discouraging the use of instrumentation,” she said, “but this is just an approach for those of us that may not have the extra instrumentation. It doesn’t mean you can’t provide good care for these patients.

“Pain is that overarching definition,” she continued. “If there’s a disconnect between signs and symptoms, think neuropathic pain. You can all do this.” – by Nancy Hemphill, ELS, FAAO

Reference:

Small L, et al. New perspectives in dry eye: Neuropathic corneal pain. Presented at: American Academy of Optometry; Chicago; Oct. 10-14, 2017.

Disclosure: Small reported no relevant financial disclosures.