November 01, 2003

Refractive Success But Extreme Pain - What's the Solution?

Matt Young 
EyeWorld Staff Writer
www.eyeworld.org/article.php?sid=823

One patient who is an apparent refractive success story — he achieved 20/20 vision after LASIK — has had extreme pain since the surgery. Bright sunlight, cold air, and slight air current cause continuous bilateral pain.

Treatments sought include recommendations by 10 corneal specialists, a multitude of Food and Drug Administration and non-FDA approved drugs, bandage lenses, and more.

Some ophthalmologists that heard of this case said it is one of the most perplexing they have reviewed and has prompted them to discuss the fine line between psychiatric and ophthalmic treatment.

Ophthalmologists weigh in

Keith Kellum, M.D., clinical assistant professor, Louisiana State University, New Orleans, said the patient, “had no obvious pathology, yet he’s having severe enough pain that he was willing to enucleate two perfectly good eyes or kill himself, so I think psychiatric would be very high” on the treatment list.

A possibility is that the patient has Munchausen’s syndrome, a psychiatric disorder in which the patient seeks out medical care for things that aren’t real, said Kellum, who participated in the Internet discussion on the patient.

Tory Prestera, M.D., Ph.D., in practice, Prestera Eye Medical Group, San Diego, said it is “a very unusual case for someone to ask for their eyes to be removed.” The problem partly appears to be psychosomatic, he said.

But Prestera, who also has discussed this case with colleagues, warned against dismissing the case as psychological. “It’s always arrogant for physicians to assume the patient doesn’t have a problem if we can’t figure it out,” he said.

Kevin Hinshaw, M.D., Eye Specialists of West County P.C., St. Louis, said the patient needs a multidisciplinary approach to his problem, which would include pain treatment and both psychiatric and ophthalmic care.

Solutions for real pain

Hinshaw, who has also discussed the case with colleagues, said a low dose of anti-depressants could make the patient’s pain less severe. Hinshaw draws his experience in pain relief from his experience as a staff ophthalmologist at a hospital burn unit.

Selective sympathetic denervation also might be an option, as the patient’s sympathetic nerves could be transmitting erroneous pain signals to his central nervous system, Hinshaw said.

If the patient was intent on having a surgical procedure, Kellum said he might consider a corneal transplant to get rid of the portion of the cornea causing so much pain. The patient might not get perfect vision back, but it would be “a heck of a lot better than blindness,” he said.

Prestera recommended using proparacaine hydrochloride, an anesthetic, to numb the eye. “It’s kind of like walking around with numb feet,” Prestera said of what the eye’s sensation would feel like after experiencing proparacaine.

A retrobulbar injection also could be used to numb the eye and paralyze its muscles, Prestera said.

Enucleation: If not now, when?

“It would be a hard thing to do, to enucleate two perfectly good seeing eyes,” Kellum said. “I could if I was absolutely convinced that this patient was going to kill himself if he didn’t get the enucleation.”

But the usual reasons for enucleation include large malignant tumors and blind painful eyes, Kellum said.

Prestera added that enucleation could be an option for a blind eye that is cosmetically displeasing, because it could then be replaced with a glass eye.

“The problem with this patient is, you always have that doubt in the back of your mind: Is this just a pure psychological thing going on and you’re going to enucleate two perfectly good eyes that have nothing wrong with them?” Kellum said.

In other patients that have some type of pathology that is causing pain, an ophthalmologist may feel more comfortable enucleating.

Hinshaw added that the patient’s desire for enucleation “seems a bit extreme,” but if all else failed, might try a penetrating keratoplasty one eye at a time for a chance of improvement.


Contact Information
Hinshaw: 314-743-0400, fax 314-743-0403, khinshaw@eswcpc.net
Kellum: 800-974-6784, fax 985-868-4190, dr2dk2@kellum-eye-center.com
Prestera: 760-598-0400, fax 760-598-5270, prestera@yahoo.com Posted by Admin at November 1, 2003 11:38 PM