The Prevalence of Dry Eye and Sjögren Syndrome in Patients with Migraine

Corneal Sensory Changes and Nerve Plexus Abnormalities in Chronic Neuropathic Ocular Pain and Dry Eye Post-Refractive Surgery

PURPOSE

Chronic neuropathic ocular pain (NOP) can develop alongside chronic dry eye (DE) post-laser-assisted in-situ keratomileusis (LASIK), yet its specific characteristics remain poorly understood. This study aims to compare the clinical characteristics of patients who developed both DE and NOP after LASIK to those with only DE and to asymptomatic LASIK patients, to facilitate the diagnosis of NOP.

METHODS

Prospective, cross-sectional "case-control" comparison study. An 89-subject post-LASIK study comprised three groups: 34 patients developing NOP and DE (NOP-DE group), 25 patients developing only DE (DE group), and 30 asymptomatic subjects (control group). Assessments included clinical history and symptom questionnaires (OSDI, mSIDEQ, NRS, WFPRS), anxiety and depression evaluation (HADS), tear film stability (osmolarity and TBUT) and production (Schirmer), and ocular surface integrity. Corneal mechanical and thermal sensitivity thresholds were measured using Belmonte's non-contact esthesiometer, whereas tactile sensitivity threshold was assessed pre/post-topical anesthesia using the Cochet-Bonnet esthesiometer. In vivo confocal microscopy (IVCM) was used to evaluate the sub-basal nerve plexus characteristics and dendritic cell density in the central cornea. Group comparisons and correlations were conducted.

RESULTS

Compared with DE group, patients in the NOP-DE group exhibited significantly more DE symptoms with mSIDEQ (p=0.019) higher level of pain with NRS and WFPRS, increased use of ocular lubrication (p=0.003), greater frequency of patients with pathological results on anxiety and depression questionnaires (p<0.001), and a higher prevalence of central sensitization syndromes (p<0.001). Additionally, NOP-DE patients demonstrated higher tactile corneal sensitivity post-topical anesthesia (p=0.002). IVCM revealed lower nerve density (p=0.049) and higher microneuroma density (p=0.008) in the sub-basal nerve plexus of NOP-DE patients compared to DE patients without NOP (p=0.008). Most nerve metrics correlated moderately to strongly with clinical parameters.

CONCLUSIONS

Persistent high corneal tactile sensitivity post-anesthesia, reduced nerve density and increased microneuroma density in the central cornea may serve as diagnostic indicators for confirming NOP in patients experiencing chronic DE post-LASIK. These findings underscore the potential utility of incorporating these measures into clinical assessments to improve diagnostic accuracy and guide management strategies in this patient population.

Discordant dry eye disease and chronic pain: A systematic review and meta-analysis

PURPOSE

To evaluate the relative contributions of objective and subjective indicators of dry eye disease (DED) in individuals with chronic pain conditions compared with controls.

METHODS

A systematic review and meta-analysis was conducted of studies that reported the signs and symptoms of DED and/or their prevalence in individuals with chronic pain compared with controls. International Association for the Study of Pain (IASP) International Classification of Diseases (ICD)-11 codes for chronic pain conditions were applied, and outcomes defined as DED signs and symptoms. A search strategy utilised the EMBASE, Web of Science, Cochrane Library and MEDLINE databases. Risk of bias assessment was performed with the Newcastle-Ottawa scale. Random effects meta-analysis calculated mean differences (MD) and odds ratios (OR), while subgroup analysis of different chronic pain conditions explored their relative association with the signs and symptoms of DED. Evidence certainty was evaluated using Grades of Recommendation, Assessment, Development, and Evaluation (GRADE).

RESULTS

Fourteen observational studies comprising 3,281,882 individuals were included. Meta-analysis found high quality evidence that individuals with chronic pain were more likely to experience symptoms of DED than controls (OR = 3.51 [95 %CI: 3.45,3.57]). These symptoms were more severe (MD = 18.53 [95 %CI: 11.90, 25.15]) than controls with a clinically meaningful effect size. Individuals with chronic pain had more rapid tear film disruption (MD = -2.45 [95 %CI: -4.20, -0.70]) and reduced tear production (MD = -5.57 [95 %CI: -9.56, -1.57]) compared with controls (with moderate evidence quality). High quality evidence revealed individuals with chronic pain had lower basal tear production (anaesthetised) than controls (MD = -2.59 [95 %CI: -3.60, -1.58]). Tear film osmolarity showed no significant differences between the chronic pain and pain-free groups. Group differences for DED signs were not considered clinically meaningful.

CONCLUSION

More severe, clinically meaningful symptoms of DED were reported in individuals with chronic pain than controls, however group differences for the signs of DED were typically of limited or questionable clinical relevance. This ocular phenotype where DED is felt more than it is seen in chronic pain may reflect underlying sensory hypersensitivity, shared by both conditions and contributing to their frequent comorbidity. Advancing understanding of this potential pathophysiological mechanism may guide clinical management.

Alterations in the tear film and ocular surface in pediatric migraine patients

PURPOSE

To evaluate the ocular surface (OS) parameters in the pediatric migraine patients (PMPs).

METHODS

This prospective case-control study consisted of 51 PMPs (PMP group) and 55 healthy pediatric patients (HPP group). In all participants, tear function was evaluated subjectively using the Ocular Surface Disease Index (OSDI) questionnaire, objectively using Schirmer tear test (STT) and tear film disintegration time (TBUT), and with clinical and laboratory examinations (conjunctival impression cytology). The PMP group was subdivided into two groups according to their aura.

RESULTS

The mean age and gender distribution of the study groups were almost the same ( P > 0.05 for both of them). In the PMP group, both the STT value and the TBUT value were significantly lower than those determined in the HPP group ( P = 0.021 and P = 0.018, respectively). In the PMP group, the OSDI scores were higher than those in the HPP group ( P = 0.032). In the PMP group, the goblet cell density values were lower than those in the HPP group ( P = 0.01). With regard to the aura, the TBUT and STT values were nonsignificantly lower in the PMP aura-positive group than in the PMP aura-negative group ( P > 0.05 for both of them). The OSDI assessment was similar in both the groups. With regard to the goblet cell count, it was observed to be less in the PMP aura-positive group than in the PMP aura-negative group ( P = 0.01).

CONCLUSION

Influence of OS in children with migraine was also demonstrated using the samples taken from the conjunctiva. These changes were also demonstrated by objective tests such as STT and TBUT. Both clinical objective evaluations and pathologic changes were more prominent in the migraine with aura group.

Analysis of the ocular surface functional unit in episodic migraine

AIM

Migraine is a chronic neurovascular disease that affects the trigeminovascular system. The purpose of this study was to evaluate corneal subbasal nerve fibers, dendritic cells and to measure tear film parameters in migraine.

PATIENTS AND METHODS

87 eyes of 44 patients suffering from migraine with a mean age of 33.23 ± 11.41 years were included in our study. 25 age-matched controls (mean age of 30.16 ± 12.59 years; P = 0.162) were recruited. The corneal subbasal plexus and the dendritic cells (DC) were analyzed using in vivo confocal microscopy (Heidelberg Retina Tomograph II Rostock Cornea Module; Heidelberg Engineering GmbH), and the tear film was imaged using LacryDiag (Quantel Medical, France).

RESULTS

Regarding the subbasal nerve fibers of the cornea, none of the examined parameters differed significantly in migraine patients from controls. We found a significant increase in the corneal DC density (P < 0.0001) and DC area (P < 0.0001) in migraine patients compared to healthy volunteers. DC density showed a positive correlation with the monthly attack frequency (r = 0.32, P = 0.041) and the DC area a negative correlation with corneal nerve branch density (r = -0.233, P = 0.039), nerve fiber length (r = -0.232, P = 0.04) and total branch density (r = -0.233, P = 0.039). Using LacryDiag a significant loss of Meibomian gland area could be detected on the superior eyelid (P = 0.005) in migraine.

CONCLUSIONS

Our results suggest the presence of neuroinflammation in the cornea of migraine patients affecting the peripheral trigeminal system. Dendritic cells surrounding the subbasal plexus may be involved in the activation and modulation of pain in migraine.

TFOS Lifestyle: Impact of lifestyle challenges on the ocular surface

Many factors in the domains of mental, physical, and social health have been associated with various ocular surface diseases, with most of the focus centered on aspects of dry eye disease (DED). Regarding mental health factors, several cross-sectional studies have noted associations between depression and anxiety, and medications used to treat these disorders, and DED symptoms. Sleep disorders (both involving quality and quantity of sleep) have also been associated with DED symptoms. Under the domain of physical health, several factors have been linked to meibomian gland abnormalities, including obesity and face mask wear. Cross-sectional studies have also linked chronic pain conditions, specifically migraine, chronic pain syndrome and fibromyalgia, to DED, principally focusing on DED symptoms. A systematic review and meta-analysis reviewed available data and concluded that various chronic pain conditions increased the risk of DED (variably defined), with odds ratios ranging from 1.60 to 2.16. However, heterogeneity was noted, highlighting the need for additional studies examining the impact of chronic pain on DED signs and subtype (evaporative versus aqueous deficient). With respect to societal factors, tobacco use has been most closely linked to tear instability, cocaine to decreased corneal sensitivity, and alcohol to tear film disturbances and DED symptoms.

In Vivo Confocal Microscopy in Different Types of Dry Eye and Meibomian Gland Dysfunction

In vivo confocal microscopy (IVCM) imaging is increasingly popular in ocular surface disease diagnosis and management. We conducted a systematic review to update the use of IVCM in the diagnosis and treatment of dry eye and meibomian gland dysfunction (MGD). A literature review was conducted on IVCM studies in MGD, dry eye disease, systemic disease causing dry eye, dry eye in glaucoma patients, contact lens-associated ocular conditions, graft-versus-host disease, and Sjogren’s syndrome-related dry eye. The articles were identified through PubMed and a total number of 63 eligible publications were analyzed in detail. All primary research studies on confocal microscopy on dry eye and related conditions from 2017 onwards were included. The reports were reviewed for their contribution to the existing literature as well as potential biases and drawbacks. Despite limitations such as small field of view, lack of population-based norms, and lack of standardization of image acquisition, interpretation, and quantification, IVCM is useful as a complementary technique for clinical diagnosis in various ocular surface disorders related to dry eye. With advances in hardware and software in the near future, it has the potential for further practical impact.

Headache and immunological/autoimmune disorders: a comprehensive review of available epidemiological evidence with insights on potential underlying mechanisms

Several lines of evidence support a role of the immune system in headache pathogenesis, with particular regard to migraine. Firstly, alterations in cytokine profile and in lymphocyte subsets have been reported in headache patients. Secondly, several genetic and environmental pathogenic factors seem to be frequently shared by headache and immunological/autoimmune diseases. Accordingly, immunological alterations in primary headaches, in particular in migraine, have been suggested to predispose some patients to the development of immunological and autoimmune diseases. On the other hand, pathogenic mechanisms underlying autoimmune disorders, in some cases, seem to favour the onset of headache. Therefore, an association between headache and immunological/autoimmune disorders has been thoroughly investigated in the last years. The knowledge of this possible association may have relevant implications in the clinical practice when deciding diagnostic and therapeutic approaches. The present review summarizes findings to date regarding the plausible relationship between headache and immunological/autoimmune disorders, starting from a description of immunological alteration of primary headaches, and moving onward to the evidence supporting a potential link between headache and each specific autoimmune/immunological disease.

Photophobia: shared pathophysiology underlying dry eye disease, migraine and traumatic brain injury leading to central neuroplasticity of the trigeminothalamic pathway

BACKGROUND

Photophobia is a potentially debilitating symptom often found in dry eye disease (DE), migraine and traumatic brain injury (TBI).

METHODS

We conducted a review of the literature via a PubMed search of English language articles with a focus on how photophobia may relate to a shared pathophysiology across DE, migraine and TBI.

RESULTS

DE, migraine and TBI are common conditions in the general population, are often comorbid, and share photophobia as a symptom. Across the three conditions, neural dysregulation of peripheral and central nervous system components is implicated in photophobia in various animal models and in humans. Enhanced activity of the neuropeptide calcitonin gene-related peptide (CGRP) is closely linked to photophobia. Current therapies for photophobia include glasses which shield the eyes from specific wavelengths, botulinum toxin, and inhibition of CGRP and its receptor. Many individuals have persistent photophobia despite the use of these therapies, and thus, development of new therapies is needed.

CONCLUSIONS

The presence of photophobia in DE, migraine and TBI suggests shared trigeminothalamic pathophysiologic mechanisms, as explained by central neuroplasticity and hypersensitivity mediated by neuropeptide CGRP. Treatment strategies which target neural pathways (ie, oral neuromodulators, transcutaneous nerve stimulation) should be considered in patients with persistent photophobia, specifically in individuals with DE whose symptoms are not controlled with traditional therapies.

Exploring the Link Between Dry Eye and Migraine: From Eye to Brain

Dry eye and migraine are common diseases with large societal and economic burdens that have recently been associated in the literature. This review outlines the link between dry eye and migraine, which may have implications for reducing their respective burdens. We highlight possible shared pathophysiology, including peripheral and central sensitization, as the potential link between dry eye and migraine. Finally, therapies targeting similar pathophysiological mechanisms between dry eye and migraine are discussed.

Investigation of light-induced lacrimation and pupillary responses in episodic migraine

The purpose of this pilot study was to investigate the light-induced pupillary and lacrimation responses mediated by intrinsically photosensitive retinal ganglion cells (ipRGCs) in migraine. Ten participants with episodic migraine and normal tear production, as well as eleven visually normal controls participated in this study. Following an initial baseline trial (no light flash), participants received seven incremental and alternating red and blue light flashes. Pupillometry recording of the left eye and a 1-min anesthetized Schirmer’s test of the right eye (using 0.5% proparacaine) were performed simultaneously. Intrinsic and extrinsic ipRGC photoactivities did not differ between migraine participants and controls across all intensities and wavelengths. Migraine participants, however, had significantly lower lacrimation than controls following the highest blue intensity. A positive correlation was found between melanopsin-driven post-illumination pupillary responses and lacrimation following blue stimulation in both groups. Our results show that participants with self-reported photophobia have normal ipRGC-driven responses, suggesting that photophobia and pupillary function may be mediated by distinct ipRGC circuits. The positive correlation between melanopsin-driven pupillary responses and light-induced lacrimation suggests the afferent arm of the light-induced lacrimation reflex is melanopsin-mediated and functions normally in migraine. Lastly, the reduced melanopsin-mediated lacrimation at the highest stimulus suggests the efferent arm of the lacrimation reflex is attenuated under certain conditions, which may be a harbinger of dry eye in migraine.

Association Between Dry Eye Disease and Migraine Headaches in a Large Population-Based Study

Importance

Reports in the literature have conflicting findings about an association between dry eye disease (DED) and migraine headaches.

Objective

To determine the strength of the association between DED and migraine headaches.

Design, Setting, and Participants

This retrospective case-control study included 72 969 patients older than 18 years from University of North Carolina-affiliated health care facilities from May 1, 2008, through May 31, 2018. Deidentified aggregate patient data were queried; data were analyzed from June 1 through June 30, 2018.

Exposures

Diagnosis of migraine headache.

Main Outcomes and Measures

Odds ratios calculated between DED and migraine headaches for participants as a whole and stratified by sex and age group.

Results

The base population consisted of 72 969 patients, including 41 764 men (57.2%) and 31 205 women (42.8%). Of these, 5352 patients (7.3%) carried a diagnosis of migraine headache, and 9638 (13.2%) carried a diagnosis of DED. The odds of having DED given a diagnosis of migraine headaches was 1.72 (95% CI, 1.60-1.85) times higher than that of patients without migraine headaches. After accounting for multiple confounding factors, the odds of having DED given a diagnosis of migraine headaches was 1.42 (95% CI, 1.20-1.68) times higher than that of patients without migraine headaches.

Conclusions and Relevance

These findings suggest that patients with migraine headaches are more likely to have comorbid DED compared with the general population. Although this association may not reflect cause and effect if unidentified confounders account for the results, these data suggest that patients with migraine headaches may be at risk of carrying a comorbid diagnosis of DED.

Transient Neurologic Dysfunction in Migraine

Transient disturbances in neurologic function are disturbing features of migraine attacks. Aura types include binocular visual, hemi-sensory, language and unilateral motor symptoms. Because of the gradual spreading quality of visual and sensory symptoms, they were thought to arise from the cerebral cortex. Motor symptoms previously included as a type of migraine aura were reclassified as a component of hemiplegic migraine. ICHD-3 criteria of the International Headache Society, added brainstem aura and retinal aura as separate subtypes. The susceptibility to all types of aura is likely to be included by complex and perhaps epigenetic factors.

Photophobia and sensations of dryness in patients with migraine occur independent of baseline tear volume and improve following botulinum toxin A injections

BACKGROUND

To evaluate the efficacy of botulinum toxin A (BoNT-A) in reducing photophobia and dry eye symptoms in individuals with chronic migraine. Additionally, we aimed to evaluate tear film volume as a potential contributor to symptoms in these patients.

METHODS

Retrospective review of 76 patients who received BoNT-A for chronic migraine between 23 August 2017 and 13 December 2017 at the Miami Veterans Affairs Medical Center Neurotoxin Clinic. Demographic data and all comorbidities were queried via chart review. Standardised validated surveys were administered to assess symptoms prior to and after BoNT-A injection. Preinjection tear volumes were obtained using the phenol red thread (PRT) test.

RESULTS

Preinjection migraine, photophobia and dry eye symptom scores were all significantly correlated, p<0.05, and none were associated with preinjection PRT results. After BoNT-A, improvements in migraine, photophobia and dry eye symptoms were also significantly correlated, p<0.05 and similarly did not associate with preinjection PRT results. Photophobia scores significantly improved following BoNT-A, while dry eye symptoms significantly improved in those with severe symptoms at baseline (DEQ-5 score ≥12), p=0.027. In logistic regression analysis of all individuals with dry eye symptoms (DEQ-5 ≥6), individuals with more severe dry eye symptoms were more likely improve, OR 1.27, 95% CI 1.06 to 1.51, p<0.01.

CONCLUSIONS

BoNT-A significantly improved photophobia in patients being treated for migraine and also improved dry eye symptoms in patients with severe symptoms at baseline, independent of baseline tear film volume. These improvements may be due to modulation of shared trigeminal neural pathways.

More Than Meets the Eye: The Eye and Migraine-What You Need to Know

Migraine has long been associated with disturbances of vision, especially migraine with aura. However, the eye plays an important role in sensory processing as well. We have found that the visual quality of life is reduced in migraine. In this review, we discuss how the migraine and eye pain pathways are similar and affect many of the common complaints which are seen in ophthalmology and neuro-ophthalmology offices, such as dry eye and postoperative eye pain. We also review other related phenomena, including visual snow and photophobia, which also are related to altered sensory processing in migraine.

Association Between Migraine and Dry Eye Disease: A Nationwide Population-Based Study

PURPOSE

Despite the possible association between migraine and dry eye disease (DED), there are only a few studies investigating this link in a relatively limited number of patients. Therefore, we have analyzed the relationship between migraine and DED in the Korean population.

MATERIALS AND METHODS

This population-based cross-sectional study included 14 329 adults participating in the fifth annual Korea National Health and Nutrition Examination Survey from 2010 to 2012. Migraine, DED diagnosis, and DED symptoms were assessed using questionnaires and surveys. Data were analyzed using logistic regression to determine the association of migraine with DED while controlling for demographic, lifestyle, and medical factors.

RESULTS

Individuals with migraine were more likely to report a DED diagnosis (14.4% vs. 8.2%, p < 0.0001) and DED symptoms (22.0% vs. 15.1%, p < 0.0001). In a multivariate analysis, the association between migraine and DED diagnosis was significant after adjustments (OR, 1.577; 95% CI, 1.340-1.855). The association between migraine and DED symptoms showed a similar pattern (OR, 1.304; 95%CI, 1.151-1.502).

CONCLUSIONS

Although a causal relationship was not revealed, we found that patients who had a lifetime history of migraine were more likely to suffer from DED than individuals who did not present with headaches; this association may require confirmation. Large prospective cohort studies are required to evaluate the association between migraine and DED, as well as the influence of DED treatment on the frequency and severity of migraine attacks.