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Categories: Shooting Star Tattoo | Author: admin 16.05.2015

Purpose: To characterize the clinical features and identify possible factors predictive of long-term, severely disabling corneal pain and photophobia following laser keratorefractive surgery.
Methods: Data from the medical records of 100 consecutive patients diagnosed with centralized corneal pain were screened retrospectively.
Results: The characterization of long-term corneal neuropathic pain following laser keratorefractive surgery and assessment of possible risk factors.
Conclusions: The duration of centralized corneal neuropathic pain exceeded 2 years at the time of the initial consultation in all patients. To characterize the clinical features and identify possible factors predictive of long-term, severely disabling corneal pain often associated with photophobia following laser keratorefractive surgery. Characterization of long-term corneal neuropathic pain following laser keratorefractive surgery and assessment of possible risk factors. The duration of putative centralized corneal neuropathic pain exceeded 2 years at the time of our initial consultation in all patients. Extensive corneal axotomies associated with laser keratorefractive procedures can trigger a chronic trigeminal pain syndrome consistent with centralized neuropathic corneal pain and distinct from that characterized by post operative dry eye-like symptoms which typically resolve within a year.
The authors have no proprietary or commercial interests in any material discussed in this article. Corneal axotomy can result in neuropathic pain mechanistically and clinically akin to that observed in other somatic areas following healing of surgical procedures.
The insight that dry eye-like symptoms is a form of corneal pain 4 points to the corneal nociceptive system as an important player in the spectrum of disorders collectively labeled as dry eye disease. 35 eyes of 18 patients had undergone LASIK, 4 eyes of 2 patients had been treated with photorefractive keratectomy (PRK) and one patient had undergone LASIK and PRK in fellow eyes. 20 of 21 subjects in this cohort were intolerant of scleral lens wear and some reported an unusually painful response to Schirmer’s tests. Despite the intensity and unrelenting nature of symptoms, corneal staining was absent in 27 of the 41 eyes (66%). The high density of corneal nociceptor terminals and their vulnerability to exposure would be expected to increase the vulnerability of the corneal pain system to developing aberrant anatomical and functional neuroplastic changes in its peripheral10 and central 11 circuitry that underlie neuropathic pain. On the other hand, patients described in this study differ from those who experience “typical” post LSK dry eye-like pain in a number of ways, including higher intensity, descriptors such as burning, aching, pressure, stabbing and in many of these patients, the presence of otherwise unexplainable photosensitivity (photoallodynia).
Anecdotal observations suggest that centralized corneal neuropathic pain following LKS is rare. Responsiveness to corneal anesthesia can sometimes be helpful in distinguishing between chronic peripheral and hard-wired centralized pain. The pain-free intervals between the resolution of post surgical pain and onset of neuropathic pain experienced by most patients in this cohort is a surprising finding and suggests that LKS may act as a priming event that further increases patients’ vulnerability to subsequent development of centralized corneal neuropathic pain that can occur spontaneously or can be triggered by a subsequent noxious event. I want to invite you to, please, take a look at the link below so you can be aware of the modifications made. It is important to know that the changes do NOT apply for the members who already have the Master Loyalty Card.
The reason why we decided to do these modifications is simply because the number of editions we used to have was a lot lower so getting to the Master Card was more of a challenge. Nowadays, we have a minimum of 15 editions per month so getting to the Master Card is quite fast and it was not what Mio intended when she first started with this. Recently we had way too many people not respecting the Post Limits and the Number of Cards allowed by the Card Makers. The Card Makers tried to warn the people concerned nicely way to many times and they also tried putting notes on the posts but nothing changed. Unfortunately, for this reason, we had to come up with a more drastic way to make people understand they have to respect what the Card Makers are asking. I know this message does not apply to everyone but we have decided to send it to all of our members so everyone knows the same information. Also, if you don't wanna miss other upcoming editions, we would suggest to check the club regularly.


We have also decided to include a delivery section to make the job easier for the card-makers. Our newsletters include notifications on when our competition rounds start, club event information, information on our monthly banner contest (new feature starting in September), news about updates and changes to the club, etc. We do a few monthly editions and we really need some more card makers to help out with those. Those of 21 patients who had previously undergone laser keratorefractive surgery were identified and reviewed. The recognition that centralized neuropathic corneal pain can be a complication of laser keratorefractive surgery is the first step to developing mechanism-based treatments for this overlooked, crippling and currently intractable neurological complication. The human cornea may be especially vulnerable to this disease considering its unrivaled density of nociceptors 1, their significantly lower activation thresholds 2 and unusual vulnerability to being exposed to the noxious environment. It has been suggested that chronic dry eye-like symptoms (DELS) following laser keratorefractive surgery (LKS) are the result of reduced tear secretion cause by impaired function of the afferent limb of the functional lacrimal unit 5. 21 patients in this group were identified as having undergone prior LASIK or photorefractive keratectomy (PRK). 4 of 17 patients who had developed soft contact lens intolerance prior to surgery reported dry eye-like symptoms (DELS) while not wearing the devices. The average level of pain was reported as no less than 6 on the visual analogue scale (0 represents no pain and 10 describes worse possible pain). Of the 14 with corneal staining, 11 were graded as 1+ (Oxford scale), and 2 exhibited 2+ and 3+ staining respectively (Table 3). The massive axotomies performed during LKS trigger inflammation and the consequent release of nociceptor-sensitizing proinflammatory cytokines that cause corneal hyperalgesia 9.
Moreover, this type of trigeminal neuropathic pain can involve receptive fields beyond that of the ophthalmic branch of the trigeminal nerves. She suffers from intense symptoms of CCNP despite the absence of signs of axonopathy, nerve regeneration or inflammation, thus indicating the autonomy of CCNP. Although incomplete or absent pain suppression support its central origin, total anesthetic suppression does not exclude this diagnosis since centralized corneal pain can be extinguished in some patients but only to lose this effect only to reoccur (personal observations). The considerable inter-patient variability in its clinical expressions (personal observations) fits the model of an open complex system in which the dysregulation of any of its numerous subsystems can affect the behavior of the system as a whole in unexpected ways 22.
Since autoimmune diseases are known to be associated with a higher incidence of peripheral neuropathies, we believe that the possible presence of these disorders or its history in immediate family members should be considered as red flags. I wasn't ready for it back when I started it, so I dropped it for a while until I had built up an immunity to sister complexes. It's pretty much going to be the same thing as our Moe Competition, except for the fact that characters from overly popular series weren't allowed in the contest (since they always win). Half of them will be eliminated after this round, though, so please vote to help us decide who stays and who goes! Due to the club having so many members, we aren't able to send out newsletters to all of our members. 62% of patients reported a pain-free interval between the resolution of surgical pain and onset of chronic corneal pain that ranged from 3 days to 15 years. 62% of patients reported a pain-free interval between the resolution of surgical pain and onset of chronic corneal pain which ranged from 3 days to 15 years.
That complications of axotomized corneal nerves can include severe, chronic (and perhaps permanent) neuropathic pain in susceptible patients is not surprising 3. Nevertheless, this model often fails to explain many of its clinical features 6; especially the disparity between the high intensity of symptoms and paucity of external signs 7 which was a uniform finding in this cohort.
As in the larger cohort, all patients in the post-LKS group were presumed to suffer from cornea-projected (phantom) pain as defined by the presence of signs and symptoms consistent with neuropathic changes in the central pain-signaling pathways. The duration of the chronic ocular pain ± neuropathic photosensitivity at the time of the initial visit varied from 2 to 15 years (See tables 1 and 2 for summary of histories and findings). Photoallodynia (neuropathic photosensitivity unsupported by external signs8) was noted by 17 (81%) patients.


The intensity of the pain strikingly exceeded that predicted by the status of their corneal epithelium in all patients.
The resulting hypersensitivity and hyper-responsiveness to noxious stimuli may include corneal evaporative hyperalgesia (hypersensitivity to tear evaporation.) Moreover, nerve injuries trigger a phenotypic switch in their somata from conduction to regenerative states that initiate the expression of hypersensitive and hyper-responsive ectopic pain generators 10 which are transported to and embedded in the neural membranes of regenerating axon terminals (sprouts and microneuromas) 11.
Vulnerability to neuropathic pain is believed to be influenced by certain genetic and epigenetic factors 14 and efforts to develop useful predictive tests continue 15, including measurements of a individual’s endogenous sensitivity to pain 16. Increased mechanosensitivity of the bulbar conjunctiva (putatively, secondary hyperalgesia that precludes wearing scleral lenses), tactile allodynia of the skin and spontaneous pain that persists even in the presence of normal corneal nerve morphology (Fig.4c) indicate involvement of the central pain signaling circuitry independently of corneal pain signals 18-20. As a result, centralized neuropathic pain is likely to have a distinctive fingerprint in each patient in terms of its clinical expression and responsiveness to treatments. Reports that delayed treatment of post operative pain has a deleterious effect on pain outcomes 23 suggest that post LKS pain should be treated aggressively and perhaps even preemptively. Excluding the 15 year outlier, the median delay in the onset of chronic pain following LKS was 1.5 years.
On the other hand, a recently proposed neuropathic model for otherwise unexplained chronic corneal pain ± photosensitivity 8 is supported by these enigmatic findings and highlights a rare, previously unreported and devastatingly painful complication of massive axotomies caused by laser keratorefractive surgery.
Pain-focused medical histories and eye examinations, including laser in vivo confocal microscopy (LVCM) and central Cochet-Bonnet esthesiometry, had been routinely recorded in the charts of all patients. Corneal neuropathic pain (CNP) had transitioned seamlessly from acute post operative pain in 8 patients (38%) whereas in 13 (62%) the onset of chronic corneal pain was preceded by a post-surgical asymptomatic interval that ranged from 3 days to 15 years (see table 3). Notably, it is the regenerating nerve terminals that are most responsible for post surgical pain following injuries. The transition from physiological (reversible) central sensitization to pathological (neuropathic) centralized pain is believed to be caused in part by a failing central inhibitory system in which descending inhibitory signals that are normally increased in response to increased barrages of ascending pain activity causing disinhibition.
14 of 17 patients who had worn soft contact lenses prior to surgery had developed intolerance to these devices. Observations of the persistence of active nerve fiber regeneration and inflammation long after these corneas have appeared to have healed likely are plausibly cause by continued nociceptor sensitization and evaporative hyperalgesia despite the presence of reduced corneal tactile sensitivity 12. Entrenched disinhibition is believed to be due to changes of maladaptive neuroplasticity in the central nociceptive pathways17. One girl from each group will go on as a finalist to face off against each other in two championship rounds.
Of the 4 patients without a prior history of soft contact lens wear, 2 reported notable chronic pre-operative dry eye-like symptoms prior to surgery. Of the 13 patients who experienced delayed onset chronic corneal pain, symptoms consistent with centralized pain had commenced spontaneously in 10. Our winner and finalists will get a special card edition in their honor and a spot on the club's layout.
3 of the 15 female patients in this cohort were subsequently diagnosed with Sjogren’s syndrome. In the remaining 3 patients, 1 related its onset to an acute exposure to toxic levels of chlorine fumes, a second to the development of presumed bilateral adenovirus keratitis in a background of Sjogren’s syndrome and the third was subsequently diagnosed as having Sjogren’s syndrome.
Nevertheless, its mechanisms are complex, poorly understood and likely differ among patients. Extensive corneal axotomies associated with laser keratorefractive procedures can trigger a chronic pain syndrome consistent with centralized neuropathic corneal pain which is distinct from that characterized by common post-operative dry eye-like symptoms that typically resolve within a year.
The disease can transition seamlessly from post-operative physiological pain or commence after a pain-free interval. The recognition that centralized neuropathic corneal pain can be a complication of laser keratorefractive surgery is the first step to developing appropriate mechanism-based treatments for this overlooked, crippling and currently intractable neurological complication.



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