Dry eye disease is pervasive within eyecare practices. Depending on how it is defined, estimates suggest that up to one out of every three patients has a sign or symptom of dry eye disease. Fortunately, we have also witnessed many advancements both in the management and therapy for dry eye disease, including meibomian gland dysfunction. Likewise, most (if not all) of these management techniques and therapy options could also be applied to contact lens wearers who experience discomfort, although further evidence is needed to validate several of these options for lens wearers.
One of the major insights in the dry eye community that has been further studied is the role of neuropathic pain in patients who have dry eye. According to the Merck Manual (www.merckmanuals.com/professional/neurologic-disorders/pain/neuropathic-pain ), “Neuropathic pain results from damage to or dysfunction of the peripheral or central nervous system, rather than stimulation of pain receptors. Diagnosis is suggested by pain out of proportion to tissue injury, dysesthesia (e.g., burning, tingling), and signs of nerve injury detected during neurologic examination.” The scientific literature supports this, as numerous studies have shown a lack of agreement between symptoms and clinical tests in dry eye disease.
I am not sure about you, but I continue to see so many dry eye patients who have symptoms that are disproportionate to clinical signs. These patients have a true absence of tear dysfunction that is not relieved by therapy. One tip to help you differentiate between neuropathic and non-neuropathic symptoms is to apply local anesthetic to the ocular surface; if symptoms continue to persist in the presence of anesthesia, consider them neuropathic in nature.
A variety of potential treatments exist (many of them off-label), but one of the most efficacious to consider is therapeutic contact lenses (e.g., bandage soft lenses or scleral lenses). There is no doubt that these lenses can certainly improve comfort and healing in these scenarios.