Check your patient’s eyes before you write a pain prescription!

 When you read that headline you probably assumed that I meant check the eyes for dilation, a sign that someone is using drugs. But in this case, I am suggesting that you check your patient’s eyes for dryness. Dryness?

An interesting pain threshold indicator in new studies show that people with dry eye disease have an increased sensitivity to pain than those who do not have dry eyes.

Researchers discovered the odd connection in a study of women with dry eye disease, which is noted to be “symptoms of eye pain (particularly corneal pain), irritation and interference with normal visual tasks, and affects women more than men….Participants were considered to have dry eye disease if they met at least one diagnostic criteria, which included a diagnosis from a clinician, a prescription for artificial tears, or symptoms of dry eyes for at least 3 months.”

A heat “stimulus,” doesn’t sound comfortable at the least, was applied to the patient’s forearm and then the heat was gradually increased from hot to painfully hot. The point at which the participant signaled that the pain threshold had been reached was documented.

“Women with dry eye disease scored significantly lower on tests for heat pain sensitivity (P=0.03) -- a measure of overall pain sensitivity -- and heat pain suprathreshold (P=0.003) -- a measure of pain tolerance -- than women who did not have dry eyes, according to Jelle Vehof, PhD, of the University Medical Center Groningen in the Netherlands, and colleagues.”

“Ocular surface pain scores were significantly associated with worse pain sensitivity (P=0.008) and pain tolerance (P=0.003) scores, they wrote online in JAMA Ophthalmology.”

When I read this I thought that it would probably be pretty rare to find patients with dry eye disease but I was wrong. (I probably should have guessed that from all of those commercials for dry eye medications.)

Depending on the exact criteria used to define the condition, this affects between 5-35% of middle aged and older patients.

This was a huge study as well, with a population-based, cross-sectional study of 1,635 women between the ages of 20-83. They were initially identified through questionnaires that gathered the demographic data and clinical history.

Who knew?


  • Comments (6)
  • Very good, Dr. Bates. In fact, dry eye syndrome is found in many of the rheumatic disorders.

    A year or so ago  the seemingly unstoppable Venus Williams was having episodes of fatigue and muscle pain, oh and dry eyes too. I read that she went to over a dozen doctors before someone put together these symptoms and came up with Sjogren's Syndrome.

    Someone said it was trivial info and her many doctors probably thought so as well until one of them remembered that these disparate symptoms were all part of a little known disease pattern.

    Interestingly enough, that's the best thing that could have happened for Sjogren's Disease - a celebrity being diagnosed with it.

    On the bigger stage, I am fascinated with pain. Why do some people react differently to it? If you have children you are probably aware of the fact that one kid can take a tumble and end up with a pretty good case of road rash and brush it off while another one, of a similar age, can scream and carry on like someone is trying to behead them.

    There are, of course, lots of psychological factors as well but at the end of the day and under controlled situations with evidence based research we are finding out some interesting new facts about people's response to pain. I would be curious to hear your experiences with patients whose pain tolerance seems especially high or low and what you attribute it too.

    The longer I have been in medicine, the more I realize that everything is not just black and white. There are a lot of amazing shades of grey out there.

  • Thanks for bringing it up, but I'm not sure how to use this new information in practice. It's a peculiar connection for sure, but will it change your Rx writing habits? 

  • Conjunctiva sicca is associated with   rheumatic diseases is my understanding.

  • This is kind of trivial information. Don't you think?
  • Interesting - though not sure it would change my approach. I, likely would still rx my usual medication and tirade up or prescribe something else if the patient complained. Unless, I consistently saw that all dry eyed patients kept complaining their medication was not working.
    Dr. Satterfield - will you change/ modify your rx habits? Or will you wait and see and take mental notes....??