Ocular Pain

[KHE]

I posted on this forum a while ago and thought maybe you guys could offer up an opinion.

73 year old female, SP cataract surgery in both eyes with good vision afterwards.

She complains of chronic eye pain. She's been treated with every eye drop out there. She's seen multiple ophthalmologists none of whom could offer any explanation or provide any relief. She is diabetic and she has stable diabetic retinopathy. Her symptoms far exceed any clinical findings. She is not on any pain medications and does not seem to be drug seeking. She has seen ENT and she does not have sinusitis or other sinus problems.

The general consensus is that this is neurotrophic in nature and related to the diabetes.

Any thoughts on the best way to manage this person? Was considering low dose tramadol. Any other thoughts?

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[swamprat]

Curious does the pain improve with properacaine or tertracain drops?


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[lobelsteve]

I posted on this forum a while ago and thought maybe you guys could offer up an opinion.

73 year old female, SP cataract surgery in both eyes with good vision afterwards.

She complains of chronic eye pain. She's been treated with every eye drop out there. She's seen multiple ophthalmologists none of whom could offer any explanation or provide any relief. She is diabetic and she has stable diabetic retinopathy. Her symptoms far exceed any clinical findings. She is not on any pain medications and does not seem to be drug seeking. She has seen ENT and she does not have sinusitis or other sinus problems.

The general consensus is that this is neurotrophic in nature and related to the diabetes.

Any thoughts on the best way to manage this person? Was considering low dose tramadol. Any other thoughts?

Consider trials of neuropathic meds first. Bany dose gabapentin and titration slowly. Consider keppra.

 

[painfree23]

Consider trials of neuropathic meds first. Bany dose gabapentin and titration slowly. Consider keppra.

Why specifically keppra?

 

[Ducttape]

what about a sphenopalantine block?

 

[lobelsteve]

Why specifically keppra?

Lack of side effects compared to lyrica, gabapentin, cymbalta, tca.

 

[painfree23]

Lack of side effects compared to lyrica, gabapentin, cymbalta, tca.

Is keppra your neuropathic agent of choice for any neuropathic pain?

 

[Ducttape]

Not much data to support benefit from keppra - at least, there’s less benefit than the others... (which is saying a little...)

 

[lobelsteve]

Is keppra your neuropathic agent of choice for any neuropathic pain?

Only for frail, multiple med intolerance pts.

 

[Orin]

Drop some local anesthetic on V1 and see what happens; good luck getting a needle there.

You could try a superior cervical ganglion block at the SGB for a CRPS like state of the eyeball?

Is there photophobia?

 

[DODOCSS]

SPGNB worth a try too

 

[Timeoutofmind]

Agree Qtip to back of nose is def worth a try

 

[KHE]

As an optometrist, I'm not going to be doing any nerve blocks.

There is minimal photophobia and there is minimal relief with topical anesthetics.

Is this a patient who would do well with a referral to a pain management doctor such as all of you or is that type of referral going to just cause upset?

 

[lobelsteve]

As an optometrist, I'm not going to be doing any nerve blocks.

There is minimal photophobia and there is minimal relief with topical anesthetics.

Is this a patient who would do well with a referral to a pain management doctor such as all of you or is that type of referral going to just cause upset?

Based pn varied responses here you surely will have no idea what the consultant you send her to will do. It is an unusual problem but still should be treated as an uncommon presentation of a common problem, rather than a rare disease entity. Less aggressive care needs to be offered. Send her. But tell her no needles without checking in with you first.

 

[Orin]

As an optometrist, I'm not going to be doing any nerve blocks.

There is minimal photophobia and there is minimal relief with topical anesthetics.

Is this a patient who would do well with a referral to a pain management doctor such as all of you or is that type of referral going to just cause upset?

If the topical provides minimal relief, then V1 is likely not mediating the problem unless she's applying the drops improperly.

This seems like a good cases for an academic pain clinics if there's a local places. It would be best managed by someone who had a significant other who was an opthamologist/optometrist, so you could also flex your local network to see if anyone had a personal/professional relationship with someone who treated pain.

In general the amount of upset just depends on how interested the practitioner is in dealing with new and challenging problems, so it helps to know the personality of the person you'd be referring it to.

There's some pain docs like Roy Levitt at Miami, FL that has a special interest in eye conditions for pain, but I doubt most providers are very knowledgeable about it.

Neuropathic ocular pain due to dry eye is associated with multiple comorbid chronic pain syndromes

 

[Biohazard685]

Reach out to some of the docs at U Miami. A couple of them see a lot of ocular pain patients.