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Painful-blind eye: A forgotten palliative care

Painful-blind eye (PBE) is a challenging and debilitating condition that greatly affects the quality of life of patients. Although PBE can result from a variety of etiologies, currently there is no guideline or consensus on how to approach therapeutically these patients, and most treatments are experience-based. We summarized the evidence from available studies to investigate the current state of PBE treatment strategies. This review revealed that the information available about therapeutic approaches in patients with PBE is insufficient and outdated, therefore, new experimental and larger studies are needed to reach an agreement about this condition.

Ocular Neuropathic Pain: An Overview Focusing on Ocular Surface Pains

Objective

This paper reviews ocular pain with the main focus on ocular surface discomfort and dry eye pain. Anatomy, physiology, epidemiology, assessment, and treatment are discussed in this paper.

Methods

A PubMed search was conducted for studies published from 2000 to 2019 on the anatomy, pathophysiology, epidemiology, assessment, and treatment of ocular pain. Reviews, meta-analyses, and randomized clinical trials were included. Inclusion criteria focused on ocular surface discomfort, dry eye pain and neuropathic pain.

Results

A total of 112 articles were found through searches, 45 of which were selected and studied in this review.

Discussion

Pain in general can be acute or chronic. Acute pain is usually a physiologic response to a serious damage to the tissues and alleviates with pain relief treatments. Chronic pain is defined as the persistence of pain for more than three months. From another point of view, pain has been classified into either nociceptive or neuropathic. Nociceptive pain is a physiologic response to a noxious stimulus. Both central and peripheral nervous systems can be involved in the development of a neuropathic pain, which is characterized by positive or negative sensory signs, a pain perceived disproportionate to a noxious stimulus, and/or not responsive to analgesics. Chronic pain usually has a neuropathic component. Ocular surface pain is a well-known complaint after any corneal surgery. This is mainly due to abnormal regeneration of damaged corneal nerve endings and abnormal connections with adjacent nerve endings which produce spontaneous activity. Tear hyperosmolarity and the resultant ocular surface inflammation can also trigger voluntary activity of corneal nerve endings. Referral pain to the first and second division of the trigeminal nerve has been reported. Interference with vision and even sleep, which is out of proportion to the examination are among patients' complaints. All of these elements proposed the new concept of ocular neuropathic pain syndrome. The first step in conventional evaluation of ocular discomfort is search for tear insufficiency. Pathologies of lid and blinking as well as conjunctival irregularities should be addressed. Anti-inflammatory agents and, in resistant cases, systemic neuromodulators are shown to be helpful. Education on behavioral changes and reassurance are essential steps. Considering the neuropathic origin for the ocular pain, treatment modalities used for such pain in other parts of the body can be considered for this syndrome.

Retrobulbar chlorpromazine injection in a child with gliosarcoma invasion into the orbits

This paper has two main purposes: (1) to report a rare case of paediatric gliosarcoma that invaded the surrounding orbit and (2) to demonstrate chlorpromazine injection as a potential treatment option for blind, painful eye caused by tumour invasion. A 12-year-old man who presented with headaches was found to have glioblastoma multiforme and it was excised and treated with radiation and chemotherapy. Seven months later, the tumour recurred as gliosarcoma, a rare variant of glioblastoma multiforme containing distinct gliomatous and sarcomatous components. In spite of treatment, the tumour progressed and eventually invaded into the right orbit. He subsequently developed a proptotic, blind, painful eye and was treated with retrobulbar chlorpromazine injection, which provided immediate symptomatic relief.

Calcitonin Gene-Related Peptide in Blind, Painful Eyes

PURPOSE

To determine if calcitonin gene-related peptide (CGRP) is overexpressed in blind, painful eyes.

METHODS

This was a retrospective cross-sectional randomized control study conducted at a tertiary level hospital. Eight specimens of eyes enucleated by a single surgeon were included in the study. The control group patients underwent exenteration for cutaneous malignancy without intraocular involvement, while the case group was enucleated for management of blind, painful eye. Each eye was stained using immunohistochemistry for the expression of CGRP. Expression of CGRP was examined by counting the number of cells staining positive for CGRP in 5 consecutive ×40 fields in the choroid, iris, and cornea of each specimen.

RESULTS

The mean number of cells staining positively for CGRP in the choroid of blind, painful eye group was 45.5 (26.3) versus 5.5 (7.7) in nonpainful enucleated eyes. This difference was found to be statistically significant (p = 0.016). Comparison of iris and cornea did not reach statistical significance. Expression of CGRP was compared using a paired t test.

CONCLUSIONS

This study demonstrates that CGRP is overexpressed in the choroid of enucleated blind, painful eyes. Modulation of this protein may represent a meaningful, nonsurgical therapeutic strategy to addressing the blind, painful eye.

Efficacy of Care for Blind Painful Eyes

PURPOSE

Pain relief for a blind painful eye often follows an escalating paradigm of interventions. This study compares the efficacy of common interventions.

METHODS

A retrospective chart review of blind painful eye cases was conducted at a single tertiary institution from April 2012 to December 2016. Demographics, etiology, treatment, and pain level were assessed.

RESULTS

Among 99 blind painful eyes, 96 eyes initially received medical therapy (topical steroids, cycloplegics, and/or hypotensives), with pain relief in 39% of eyes. Minimally invasive interventions (laser cyclophotocoagulation, retrobulbar injection, or corneal electrocautery) were performed 41 times in 36 eyes, 34 of which had failed medical therapy, and led to pain relief in 75% of eyes. Evisceration or enucleation was performed in 28 eyes, and long-term pain relief was achieved in 100% of eyes. Surgery allowed discontinuation of oral analgesics in 100% of cases versus 20% for minimally invasive therapy (p = 0.005) and 14% for medical therapy (p = 0.0001). Compared with medical therapy, minimally invasive therapy was 2.5 times more likely to achieve lasting pain relief (p = 0.003) and surgical therapy 35.6 times more likely to achieve lasting pain relief (p = 0.011). High initial pain score was associated with nonsurgical treatment failure.

CONCLUSIONS

Medical therapy provides pain relief in a moderate number of patients with a blind painful eye. When medical therapy fails, minimally invasive therapy and surgical interventions are successively more effective in relieving ocular pain. High initial pain score is a risk factor for nonsurgical therapy failure and may merit an earlier discussion of surgical intervention.

A decade of surgical eye removals in Ontario: a clinical-pathological study

OBJECTIVE

To assess patient demographics, clinical indications, and pathologic causes of surgically removed eyes over a decade in Ontario (Canada) and to identify areas of ocular disease management needing more attention.

DESIGN

Retrospective cross-sectional study.

PARTICIPANTS

The surgically removed eyes of 713 consecutive mainly adult patients from 2004 to 2013.

METHODS

Demographic, clinical, and pathologic data were collected on all eyes received by the University of Toronto Ophthalmic Pathology Laboratory from 2004 to 2013.

RESULTS

Of the 713 eyes removed, enucleations accounted for 60% of cases, eviscerations for 39% of cases, and exenteration for 1% of cases. The most common clinical indications for surgical eye removal were blind painful eye (37%), neoplasm (35%), and trauma (6%). The leading pathologic causes of eye removal were neoplasm (36%), glaucoma (21%), infection or inflammation (17%), and trauma (16%). Glaucoma-related findings were the most common pathologic findings observed (38%), regardless of the primary cause.

CONCLUSIONS

A blind painful eye and neoplasms were the most commonly documented indications prior to removal of the eye. Common pathologies included glaucoma, neoplasms, infection/inflammation, and trauma. However, regardless of the primary cause, glaucoma-related pathologies were the most common pathologic findings. Refractory eye disease and pain continue to be important reasons for removal of eyes among patients in Ontario. More effective and targeted management strategies are needed to reduce the need for this radical eye surgery of last resort.

Retrobulbar chlorpromazine in management of painful eye in blind or low vision patients

OBJECTIVE

To evaluate the results of applying retrobulbar chlorpromazine in the management of patients with painful blind eyes or with very poor vision.

METHODS

A retrospective, descriptive review was carried out on the medical records of 33 patients who were treated with a retrobulbar injection of chlorpromazine (25mg) for the management of painful blind eyes in Centro Oftalmológico Virgilio Galvis.

RESULTS

Pain control was achieved in 90% of cases (with mean follow-up of 2.1 years). The mean intraocular pressure decreased by 37%. In 7 out of 12 eyes that maintained residual vision, loss of some degree of vision was acknowledged. One patient required an additional cyclodestructive procedure, another one required an absolute alcohol injection, and in an additional case evisceration surgery was necessary to achieve pain control. No serious complications were noted with this therapy.

CONCLUSIONS

Retrobulbar injection of chlorpromazine is a valid option in painful, blind eye cases (or with very poor vision) with a poor visual prognosis.