Neuropathic Ocular Pain Diagnosis and Management

Introduction to Neuropathic Ocular Pain

The American Academy of Ophthalmology suggests that neuropathic ocular pain should be suspected when symptoms significantly outweigh clinical signs, pain persists despite appropriate treatment of ocular surface abnormalities, and pain is described as burning, stinging, or aching with photophobia and wind sensitivity 1, 2, 3
A history of prior ocular surgery, infection, or chronic dry eye can contribute to the development of neuropathic ocular pain 1, 4

The diagnostic anesthetic challenge test can help differentiate between peripheral neuropathic or nociceptive component and central or non-ocular cause of pain, with pain improvement suggesting peripheral neuropathic or nociceptive component and persistent pain suggesting central or non-ocular cause 2, 3

The treatment approach for neuropathic ocular pain may involve autologous serum tears for the peripheral component 2, 3, 5
Oral neuromodulators such as pregabalin, gabapentin, duloxetine, amitriptyline, nortriptyline, and low-dose naltrexone may be used for the central component 2, 3, 5
Transcutaneous electrical nerve stimulation or periorbital botulinum toxin A may be considered for patients with photophobia or headache 2, 5
Periocular nerve blocks with corticosteroid and long-acting sodium channel blocker may be used for postsurgical or allodynia cases 2, 5
A multidisciplinary approach involving ophthalmology, pain specialists, neurology, and mental health professionals is recommended due to high rates of comorbid anxiety and depression 2, 3, 5