Is gabapentin effective in dry eye disease and neuropathic ocular pain?

When ocular surface treatment fails: exploring neuropathic ocular pain in aqueous-deficient dry eye due to Sjögren's syndrome treated with mirogabalin: a case study

Dry eye disease can be classified as aqueous-deficient, evaporative and mixed-type. Recently, neuropathic pain has been indicated to be involved in the subjective symptoms of aqueous-deficient dry eye. However, the mechanism underlying neuropathic ocular pain in such patients remains elusive. Here, we present the case of a patient with aqueous-deficient dry eye disease and severe corneal and conjunctival epithelial damage due to Sjögren's syndrome. Despite considerable improvements in ocular surface conditions with local treatments, such as punctal plugs, autologous serum eye drops, rebamipide eye drops, and tacrolimus eye drops, the patient experienced severe ocular pain for two years, which was disproportionate to the objective clinical findings. The pain worsened during the exacerbations of systemic symptom, such as arthritis and interstitial pneumonia, without correlating with the ocular surface findings. The administration of mirogabalin, a neuropathic pain medication, effectively alleviated the patient's subjective ocular pain symptoms. Ocular pain in patients with Sjögren's syndrome is not necessarily linked to an aqueous deficiency or ocular surface findings. It can arise as neuropathic ocular pain due to inflammation spreading to the trigeminal nerve. Given the systemic inflammatory condition and characteristics of the ocular pain, administering neuropathic pain medications should be considered as a treatment option.

[Pharmacological correction of burning eye syndrome]

Burning eye syndrome (BES) is a subtype of dry eye syndrome (DES) characterized by neuropathic pain that is resistant to conventional DES therapy aimed at restoring tear film stability. The lack of impact on the corneal neural pathways is the reason for ineffectiveness of such treatment.

PURPOSE

This study evaluated the effectiveness of a novel treatment regimen for BES.

MATERIAL AND METHODS

The study included patients aged 18-45 years diagnosed with BES. The criterion for exclusion from the study was the presence of clinical signs of blepharitis, meibomian gland dysfunction, as well as existing rheumatologic or oncologic diseases. The follow-up period was 12 months. All patients underwent standard and specialized ophthalmic examinations. They were randomly assigned to two groups: group 1 received gabapentin combined with neuroprotective therapy (thioctic acid, ipidacrine, and B vitamins) and topical 0.4% hyaluronic acid (HA) four times daily, while group 2 received only tear substitution therapy with 0.4% HA four times daily. Treatment efficacy was assessed using subjective (the Russian version of the Central Sensitization Inventory (CSI-20) and Visual Analog Scale (VAS)) and objective (laser corneal confocal microscopy and tearscopy) evaluation methods. Therapeutic effectiveness was assessed at 3, 6, and 12 months.

RESULTS

By the third month, patients in group 1 reported subjective improvement based on CSI-20 and VAS scores, while objective findings demonstrated decreased tear osmolarity, increased anisotropy coefficient of nerve fiber orientation, and an increase in nerve fiber length. No significant changes were observed in group 2 over the same period.

CONCLUSION

The proposed treatment regimen, incorporating gabapentin along with neuroprotective therapy (thioctic acid, ipidacrine, and B vitamins) and topical 0.4% HA, proved more effective in alleviating neuropathic pain in BES compared to isolated topical therapy.

Corneal neuropathic pain: a review to inform clinical practice

Corneal neuropathic pain (CNP) is a poorly defined disease entity characterised by an aberrant pain response to normally non-painful stimuli and categorised into having peripheral and central mechanisms, with the former responding to instillation of topical anaesthetic. CNP is a challenging condition to diagnose due to numerous aetiologies, an absence of clinical signs and ancillary tests (in vivo confocal microscopy and esthesiometry), lacking the ability to confirm the diagnosis and having limited availability. Symptomatology maybe mirrored by severe and chronic forms of dry eye disease (DED), often leading to misdiagnosis and inadequate treatment. In practice, patients with suspected CNP can be assessed with questionnaires to elicit symptoms. A thorough ocular assessment is also performed to exclude any co-existent ocular conditions. A medical and mental health history should be sought due to associations with autoimmune disease, chronic pain syndromes, anxiety and depression. Management begins with communicating to the patient the nature of their condition. Ophthalmologists can prescribe topical therapies such as autologous serum eyedrops to optimise the ocular surface and promote neural regeneration. However, a multi-disciplinary treatment approach is often required, including mental health support, particularly when there are central mechanisms. General practitioners, pain specialists, neurologists and psychologists may be needed to assist with oral and behavioural therapies. Less data is available to support the safety and efficacy of adjuvant and surgical therapies and the long-term natural history remains to be determined. Hence clinical trials and registry studies are urgently needed to fill these data gaps with the aim to improve patient care.

Molecular Mechanisms and Therapeutic Potential of Gabapentin with a Focus on Topical Formulations to Treat Ocular Surface Diseases

Gabapentin (GBP) was originally developed as a potential agonist for Gamma-Amino-Butyric-Acid (GABA) receptors, aiming to inhibit the activation of pain-signaling neurons. Contrary to initial expectations, it does not bind to GABA receptors. Instead, it exhibits several distinct pharmacological activities, including: (1) binding to the alpha-2-delta protein subunit of voltage-gated calcium channels in the central nervous system, thereby blocking the excitatory influx of calcium; (2) reducing the expression and phosphorylation of CaMKII via modulation of ERK1/2 phosphorylation; (3) inhibiting glutamate release and interfering with the activation of NMDA receptors; (4) enhancing GABA synthesis; (5) increasing cell-surface expression of δGABA_A receptors, contributing to its antinociceptive, anticonvulsant, and anxiolytic-like effects. Additionally, GBP displays (6) inhibition of NF-kB activation and subsequent production of inflammatory cytokines, and (7) stimulation of the purinergic adenosine A1 receptor, which supports its anti-inflammatory and wound-healing properties. Initially approved for treating seizures and postherpetic neuralgia, GBP is now broadly used for various conditions, including psychiatric disorders, acute and chronic neuropathic pain, and sleep disturbances. Recently, as an eye drop formulation, it has also been explored as a therapeutic option for ocular surface discomfort in conditions such as dry eye, neurotrophic keratitis, corneal ulcers, and neuropathic ocular pain. This review aims to summarize the evidence supporting the molecular effects of GBP, with a special emphasis on its applications in ocular surface diseases.

Association between systemic medication use and severity of dry eye signs and symptoms in the DRy eye assessment and management (DREAM) study

PURPOSE

Some systemic medications are reported to be associated with dry eye disease (DED), yet their associations with the severity of DED signs and symptoms are not well studied. To evaluate these associations, we performed a secondary analysis of data from the DRy Eye Assessment and Management (DREAM) Study.

METHODS

Participants (N = 535) were assessed for DED signs using tear break-up time (TBUT), Schirmer testing, corneal fluorescein staining, conjunctival lissamine green staining, meibomian gland dysfunction (MGD), and tear osmolarity and DED symptoms using the Ocular Surface Disease Index (OSDI). We derived a composite signs severity score from the 6 DED signs and categorized participant-reported systemic medications into antidepressants, antihistamines, aspirin, corticosteroids, diuretics, nonsteroidal anti-inflammatory drugs, proton pump inhibitors, statins, vitamin D3, and medications for diabetes mellitus, hypertension, hypothyroidism, migraine, and seizure. Generalized linear models were used to compare DED symptom and sign scores between medication users and non-users, with adjustment for factors associated with DED severity.

RESULTS

Compared to non-users, antihistamine users had lower TBUT (p = 0.01) and higher OSDI score (p = 0.02); aspirin users had lower TBUT (p = 0.02); corticosteroid users had lower TBUT (p = 0.02), lower Schirmer test scores (p = 0.03), higher cornea fluorescein staining (p = 0.01), higher composite severity score (p = 0.01), and higher OSDI score (p = 0.03); seizure medication users had higher composite severity score (p = 0.02); vitamin D3 users had lower TBUT (p = 0.001) and greater MGD (p = 0.03); and diuretic users had less MGD (p = 0.03).

CONCLUSIONS

Certain systemic medications may be associated with more severe DED. This may guide prescription practices in patients with DED.

Aquaporins in the Cornea

The cornea is an avascular, transparent tissue that allows light to enter the visual system. Accurate vision requires proper maintenance of the cornea's integrity and structure. Due to its exposure to the external environment, the cornea is prone to injury and must undergo proper wound healing to restore vision. Aquaporins (AQPs) are a family of water channels important for passive water transport and, in some family members, the transport of other small molecules; AQPs are expressed in all layers of the cornea. Although their functions as water channels are well established, the direct function of AQPs in the cornea is still being determined and is the focus of this review. AQPs, primarily AQP1, AQP3, and AQP5, have been found to play an important role in maintaining water homeostasis, the corneal structure in relation to proper hydration, and stress responses, as well as wound healing in all layers of the cornea. Due to their many functions in the cornea, the identification of drug targets that modulate the expression of AQPs in the cornea could be beneficial to promote corneal wound healing and restore proper function of this tissue crucial for vision.

Inflammation mechanism and anti-inflammatory therapy of dry eye

Dry eye is a widespread chronic inflammatory disease that causes fatigue, tingling, burning, and other symptoms. Dry eye is attributed to rheumatic diseases, diabetes, hormone disorders, and contact lenses, which activate inflammatory pathways: mitogen-activated protein kinases (MAPK) and nuclear factor-B (NF-κB), promote macrophage inflammatory cell and T cell activation, and inflammation factors. Clinicians use a combination of anti-inflammatory drugs to manage different symptoms of dry eye; some of these anti-inflammatory drugs are being developed. This review introduces the dry eye inflammation mechanisms and the involved inflammatory factors. We also elucidate the anti-inflammatory drug mechanism and the detection limits.

Effects of gabapentin on intraocular pressure, tear production and horizontal pupil diameter in New Zealand White rabbits

BACKGROUND

This study aimed to investigate the effects of gabapentin on various ocular parameters in New Zealand White rabbits.

METHODS

A randomised, placebo-controlled crossover study design was employed. Eight New Zealand White rabbits were randomly assigned to receive either oral gabapentin at a dosage of 15 mg/kg or an oral placebo, with a 1-week washout period between treatments. Intraocular pressure, tear production and horizontal pupil diameter were measured at baseline (T0) and at 30, 60, 90, 120, 180, 240 and 360 minutes after drug administration. Physiological and behavioural changes were also recorded for both treatments following drug administration.

RESULTS

The administration of gabapentin did not have any significant effects on the ocular parameters measured in this study. However, the rabbits exhibited some muscle relaxation with partially closed eyes during handling, and they were slightly easier to remove from the cage when treated with gabapentin compared to the placebo treatment.

LIMITATIONS

In this study, the ocular effects of gabapentin were assessed in only a small number of healthy rabbits. These effects may differ in rabbits with pre-existing eye conditions or in those receiving other medications.

CONCLUSIONS

Our findings suggest that gabapentin treatment does not have a significant impact on intraocular pressure, tear production or horizontal pupil diameter in rabbits.

Update on pharmacotherapy for dry eye

PURPOSE OF REVIEW

This review provides an overview of pharmacologic treatments for dry eye disease (DED), with a focus on newer developments.

RECENT FINDINGS

Along with the existing treatments, there are several new pharmacologic treatments available and being developed for DED.

SUMMARY

There are many currently available options for treatment of DED, and ongoing research and development to expand potential treatments for patients with DED.

[Neuropathic pain in dry eye syndrome. Part 1. Pathophysiological mechanisms of pain formation]

The review details the features and mechanisms of the formation of various types of pain. The emphasis is placed on the occurrence of pain syndrome in various ophthalmological diseases, particularly in dry eye syndrome. The article also presents literature data on the role of cytokines in the formation of a neuroinflammatory cascade affecting damage to corneal nerve fibers and the development of pain syndrome, which is a characteristic feature of a subtype of dry eye disease - burning eye syndrome.

Neuropathic ocular surface pain: Emerging drug targets and therapeutic implications

INTRODUCTION

Dysfunction at various levels of the somatosensory system can lead to ocular surface pain with a neuropathic component. Compared to nociceptive pain (due to noxious stimuli at the ocular surface), neuropathic pain tends to be chronic and refractory to therapies, making it an important source of morbidity in the population. An understanding of the options available for neuropathic ocular surface pain, including new and emerging therapies, is thus an important topic.

AREAS COVERED

This review will examine studies focusing on ocular surface pain, emphasizing those examining patients with a neuropathic component. Attention will be placed toward recent (after 2017) studies that have examined new and emerging therapies for neuropathic ocular surface pain.

EXPERT OPINION

Several therapies have been studied thus far, and continued research is needed to identify which individuals would benefit from specific therapies. Gaps in our understanding exist, especially with availability of in-clinic diagnostics for neuropathic pain. A focus on improving diagnostic capabilities and researching gene-modulating therapies could help us to provide more specific mechanism-based therapies for patients. In the meantime, continuing to uncover new modalities and examining which are likely to work depending on pain phenotype remains an important short-term goal.

Opioids and Ocular Surface Pathology; A Literature Review of New Treatments Horizons

This review discusses the role of opioids in the corneal surface and the different pathways and therapeutic methods of management. A literature review was performed using PubMed database. For the database search, the main searching words “opioid” and “topical opioid treatment” were used with the descriptors “cornea”, “ocular surface”, “neuropathic corneal pain”, “corneal sensitivity” and “naltrexone”; original scientific articles and reviews were included to achieve the purpose of the review. The endogenous opioid system has relevant functions in the organism, and in daily use, opioids are used as painkillers. However, these drugs may be employed for other indications as opioid pathways have a wide spectrum. The corneal surface for topical treatment is easily accessible, hence sparing the side effects of systemic opioids. Instillation of opioid antagonist substances, such as naltrexone, increases corneal healing rates and stimulates the division of corneal epithelium cells without deleterious effects. The natural modulation of endogenous opioids controls different forms of pain, including inflammatory and neuropathic pain, both in the ocular surface and in the central nervous system. There are diverse methods in controlling pain using opioids, especially in refractory forms. This review attempts to collect the literature about corneal surface and opioid pathways to provide an overview image and a possible direction of the news treatments.

Effects of Topical Gabapentin on Ocular Pain and Tear Secretion

Neuropathic ocular pain is a frequent occurrence in medium to severe dry eye disease (DED). Only palliative treatments, such as lubricants and anti-inflammatory drugs, are available to alleviate patients’ discomfort. Anesthetic drugs are not indicated, because they may interfere with the neural feedback between the cornea and the lacrimal gland, impairing tear production and lacrimation. Gabapentin (GBT) is a structural analog of gamma-amino butyric acid that has been used by systemic administration to provide pain relief in glaucomatous patients. We have already shown in a rabbit model system that its topic administration as eye drops has anti-inflammatory properties. We now present data on rabbits’ eyes showing that indeed GBT given topically as eye drops has analgesic but not anesthetic effects. Therefore, opposite to an anesthetic drug such as oxybuprocaine, GBT does not decrease lacrimation, but–unexpectedly–even stimulates it, apparently through the upregulation of acetylcholine and norepinephrine, and by induction of aquaporin 5 (AQP5) expression in the lacrimal gland. Moreover, data obtained in vitro on a primary human corneal epithelial cell line also show direct induction of AQP5 by GBT. This suggests that corneal cells might also contribute to the lacrimal stimulation promoted by GBT and participate with lacrimal glands in the restoration of the tear film, thus reducing friction on the ocular surface, which is a known trigger of ocular pain. In conclusion, GBT is endowed with analgesic, anti-inflammatory and secretagogue properties, all useful to treat neuropathic pain of the ocular surface, especially in case of DED.

Dry eye: why artificial tears are not always the answer

Dry eye disease (DED) is a multifactorial disease that manifests in patients with a variety of symptoms and signs such as ocular pain, visual issues, rapid tear evaporation and/or decreased tear production. It is a global health problem and is the leading cause of optometry and ophthalmology clinic visits. The mainstay therapy for DED is artificial tears (ATs), which mimics tears and improves tear stability and properties. ATs have been found to improve symptoms and signs of disease in all DED subtypes, including aqueous deficient DED and evaporative DED. However, given the heterogeneity of DED, it is not surprising that ATs are not effective in all patients. When AT fails to relieve symptoms and/or signs of DED, it is critical to identify the underlying contributors to disease and escalate therapy appropriately. This includes underlying systemic diseases, meibomian gland dysfunction, anatomical abnormalities and neuropathic dysfunction. Thus, this review will discuss the benefits and limitations of ATs and review conditions when escalation of therapy should be considered in DED.

Could contact lens dryness discomfort symptoms sometimes have a neuropathic basis?

Symptoms of dryness discomfort in soft contact lens wearers frequently lead to discontinuation from wear. The negative influence of pre-fitting tear dysfunctions appears likely to be exacerbated by the challenges to tear homeostasis caused by contact lenses. The corneal mechanisms for symptoms in contact lens wearers are different to those for dry eye disease because the cornea is insulated by the lens from ambient conditions as well as from lid wiper friction during blinking. Symptoms of dryness discomfort might be the consequence of increased lid wiper friction during blinking when the lens front surface becomes soiled and dry and exhibits very rapid tear break up. It is possible that some cases of contact lens intolerance and discontinuation could be a function of lid wiper neuropathy. In relation to the possibility of corneal neuropathy, a stagnant post-lens tear pool with the possibility of increased concentrations of metabolic by-products, cellular debris, and bacterial exotoxins, might have the potential to disturb the corneal epithelial and sub-basal nerves. Contributions by contact lens-induced inflammation to any neuropathic changes may partly depend on the degree to which inflammatory mediators are concentrated in a stagnant post-lens tear pool. It does not appear to be known if corneal neuropathic changes could develop under these conditions. The chances of neuropathic involvement may be greater if discomfort develops after a significant period of successful wear and there is a history of comorbid pain conditions. Esthesiometry and in vivo confocal microscopy in discontinued contact lens wearers may support a diagnosis of contact lens-related corneal neuralgia.

Topical TRPM8 Agonist for Relieving Neuropathic Ocular Pain in Patients with Dry Eye: A Pilot Study

Background: Activation of TRPM8, a cold-sensing receptor located on the cornea and eyelid, has the potential to relieve the neuropathic ocular pain (NOP) in dry eye (DE) by inhibiting other aberrant nociceptive inputs. We aimed to investigate the effect of a topical TRPM8 agonist, cryosim-3 (C3), on relieving DE-associated NOP. Methods: We conducted a prospective pilot study of 15 patients with DE-associated NOP. These patients applied topical C3 to their eyelid, 4 times/day for 1 month. The patients underwent clinical examinations. They also completed the Ocular Pain Assessment Survey (OPAS), which is a validated questionnaire for NOP, at baseline, 1 week, and 1 month after treatment. Result: At 1 week, the OPAS scores of eye pain intensity, quality of life (driving/watching TV, general activity, sleep, and enjoying life/relations with other people), and associated factors (burning sensation, light sensitivity, and tearing) improved. The total OPAS scores of eye pain intensity, quality of life, and associated factors remained improved at 1 month. The Schirmer test scores also improved at 1 month. Conclusion: TRPM8 agonist (C3) could be a novel agent for treating patients with DE-associated NOP who are unresponsive to conventional treatments.

Treatment Response to Gabapentin in Neuropathic Ocular Pain Associated with Dry Eye

PURPOSE

To investigate the response to gabapentin treatment in patients with dry eye (DE) accompanied by features of neuropathic ocular pain (NOP), and to analyze the differences between clinical manifestations of the groups according to treatment response.

METHODS

We retrospectively reviewed the records of 35 patients with DE accompanied by NOP features and obtained information on their medical history and previous ocular history. The patients underwent clinical examinations of the tear film, ocular surface, and meibomian gland and completed the Ocular Pain Assessment Survey (OPAS). One month after treatment with topical eye drops, add-on of gabapentin treatment was determined according to the Wong-Baker FACES Pain Rating Scale (WBFPS). A reduction of 2 points or more on the WBFPS was considered a positive treatment response. Enrolled patients were divided into three groups according to the treatment response: topical treatment response group (group 1, n = 11); gabapentin response group (group 2, n = 13); and gabapentin non-response group (group 3, n = 11). The medical history, clinical parameters, and OPAS scores were compared between groups.

RESULTS

The incidence of systemic comorbidities was higher in group 2 than in other groups. The corneal staining scores were lower in groups 2 and 3 than in group 1. Among the treatment response groups, group 2 showed improvements in OPAS scores of ocular pain severity, pain other than eyes, and quality of life, while group 1 showed improved OPAS scores of ocular pain severity and ocular associated factors. Group 2 exhibited lower scores of pains aggravated by mechanical and chemical stimuli than group 3.

CONCLUSIONS

Gabapentin could be effective in patients who have systemic comorbidity and less pain evoked by mechanical and chemical stimuli for the treatment of DE patients with NOP, which is refractory to topical treatment.

Autoimmune Dry Eye without Significant Ocular Surface Co-Morbidities and Mental Health

Dry eye symptoms can negatively affect the psychological, physical, and social functioning, which can potentially impair the health-related quality of life. This review evaluated the association between autoimmune related dry eye in the absence of significant ocular surface co-morbidities and mental health. This review found a significantly higher prevalence of mental health disorders (such as depression and anxiety) in systemic lupus erythematous, rheumatoid arthritis, systemic sclerosis, Behcet’s disease, and primary Sjogren’s syndrome patients when compared to the general population. Moreover, patients with depression and anxiety interpret ocular sensations differently than healthy controls and the perception of dry eye symptoms can be influenced by their mood. Somatization is common in depression, and this could influence the perception of ocular discomfort. Anti-depressants and anxiolytics with their potential side effects on the tear film status may also contribute or aggravate the dry eye symptoms in these patients. Although ophthalmologists manage the dry eye disease, as per standardized algorithms, they should be mindful of different ocular sensation interpretation and coexistent mental health issues in a large number of this patient group and initiate a multidisciplinary management plan in certain cases. While rheumatologists look after their autoimmune condition, it may be worth liaising with GP and/or psychiatrist colleagues in order to address their neuropathic type pain and mental health co-morbidities.

Gabapentin for presumed neuropathic ocular pain

Purpose

To report a case of chronic neuropathic ocular pain in a patient without visual complaints.

Observations

A 37-year-old male with a history of bilateral laser-assisted in situ keratomileusis (LASIK) presented with pain symptoms of 8 months duration in the left eye. The prior LASIK surgery was complicated by corneal ectasia in the left eye requiring penetrating keratoplasty and subsequent placement of a glaucoma drainage implant for uncontrolled, elevated intraocular pressure. The patient was evaluated with a complete clinical examination, including Goldmann applanation tonometry, dilated fundus examination, fluorescein angiography, optical coherence tomography, and magnetic resonance imaging. After 3 weeks of treatment with gabapentin 300 mg BID, the patient reported complete resolution of the ocular pain.

Conclusions and Importance

The pathophysiology of neuropathic ocular pain remains poorly understood. Clinical evaluation often reveals minimal ophthalmic exam findings, leading to an underdiagnosis of the condition by ophthalmologists. Gabapentin may be an underutilized medication in the treatment of chronic ocular pain.