Treatment of Ocular Pain Not Responsive to Traditional Dry Eye Disease Treatments

Neuropathic ocular pain (NOP) in dry eye disease can be a challenging condition to treat. The pathogenesis of NOP often results from injury to the corneal nerves, leading to neural plasticity and peripheral and central neuronal sensitization. These patients often present with ocular pain, allodynia, photophobia, and neuro-behavioral manifestations and seldom respond to traditional dry eye treatments. For the treatment of NOP, the goal is to use a multimodal approach addressing both the peripheral and centralized pain using a host of topical and systemic therapies. Topical therapies include contact lenses and nerve regenerative therapies such autologous serum tears. Systemic therapies often used for other neuropathic pain conditions can potentially be helpful in NOP; these medications consist of gabapentinoids and other anticonvulsants, tricyclic antidepressants, and serotonin-norepinephrine reuptake inhibitors. Further, procedural therapies such as transcutaneous electrical nerve stimulation and peri-orbital nerve blocks may be useful in patients who are refractory to topical and systemic therapies. Lastly, since NOP can have a significant negative impact on quality-of-life measures with regard to mood, sleep, activity, adjunctive behavioral therapy may be beneficial. Ultimately, a personalized multimodal therapy will often be necessary to address the complex mechanisms underlying NOP.