Maskin Steven L
Dry Eye and Cornea Treatment Center Tampa, Florida, 33609, USA.
Am J Ophthalmol Case Rep. 2022 Jul 13;27:101662. doi: 10.1016/j.ajoc.2022.101662. eCollection 2022 Sep.
To report the successful approach to managing neuropathic dry eye-like pain (NP) in three consecutive patients described as severe: 1) "burning fire," "burning acid," and "horrible burning pain" with hyperalgesia and allodynia, 2) refractory to topical anesthetic (TA), and 3) without surface hyperemia nor vital staining.
Two of three patients' pain was reversed with significant symptom relief within 48 hours by identification of occult obstructive Meibomian gland dysfunction (o-MGD) and treatment using Meibomian gland probing (MGP) with intraductal steroid lavage (MGP) and aqueous tear deficiency (ATD) treated with punctal thermocautery (PO). The third patient's pain was reversed within one week after treatment of superior conjunctivochalasis (CCh) using amniotic membrane surface reconstruction and ATD using PO with subsequent MGP and MGP for o-MGD.
It has been generally thought that central (NP) is strongly suggested by triad of 1) severe chronic burning pain with hyperalgesia and allodynia, 2) refractory to TA with 3) minimal signs. In this three-case series, treatment of surface disease consistently led to symptom reversal. Results may represent salutary effect of successful treatment to suppress nociceptive inflammation leading to reversal of central NP. Alternatively, the current triad of diagnostic criteria may be unable to differentiate centralized NP from peripheral sensitization alone, thereby requiring rigorous examination to uncover occult, yet treatable, surface disease to restore eye comfort and reverse psychosocial sequelae when possible. Furthermore, rigorous targeting of surface disease in patients with this pain triad may obviate unnecessary systemic treatments with associated risks of serious side effects.
报告连续3例被描述为严重的神经性干眼样疼痛（NP）的成功治疗方法：1）“火烧样”“酸蚀样”和“剧烈灼痛”伴痛觉过敏和异常性疼痛；2）对表面麻醉剂（TA）无效；3）无表面充血及活体染色。
3例患者中有2例通过识别隐匿性睑板腺功能障碍（o-MGD）并采用睑板腺探查（MGP）联合导管内类固醇灌洗治疗o-MGD，以及采用泪小点热烧灼（PO）治疗水性泪液缺乏（ATD），在48小时内疼痛得到缓解，症状显著减轻。第3例患者在采用羊膜表面重建治疗上睑结膜松弛（CCh），并采用PO联合后续MGP和MGP治疗o-MGD及ATD后，疼痛在1周内得到缓解。
一般认为，1）伴有痛觉过敏和异常性疼痛的严重慢性灼痛、2）对TA无效、3）体征轻微这三联征强烈提示中枢性（NP）。在这个3例系列病例中，表面疾病的治疗持续导致症状缓解。结果可能代表成功治疗抑制伤害性炎症从而逆转中枢性NP的有益效果。或者说，当前的三联征诊断标准可能无法仅将中枢性NP与外周敏化区分开来，因此需要进行严格检查以发现隐匿但可治疗的表面疾病，尽可能恢复眼部舒适度并逆转心理社会后遗症。此外，对具有这种疼痛三联征的患者严格针对表面疾病进行治疗，可能避免不必要的全身治疗及其相关的严重副作用风险。
