持续、严重的乾眼症与疼痛、非眼部因素有关


  【24drs.com】在线发表于12月22日JAMA眼科学期刊的一篇纵向研究中,研究者确认了预测一年后之乾眼症状的因素。虽然研究结果可能不适用于非退伍军人,研究者强调,疼痛感知和严重度对于一年预后的重要性。
  
  佛罗里达迈阿密退伍军人医学中心退伍军人事务部Bruce W. Carter眼科部Erin S. Ong等人写道,原本即有严重乾眼症状的患者,大多数在一年时表示仍有持续的严重症状。对于原本的疼痛性和神经性眼部疼痛,除了睡眠障碍、精神健康状况,非眼部疼痛和药物也是风险因素。
  
  乾眼症非常普遍,影响了数百万人;虽然以前的横断面研究检视了乾眼严重程度的风险因素,很少研究探讨风险因素或症状随著时间的变化。
  
  作者们写道,这篇研究强调了疼痛严重度和认知对于乾眼症之严重度与持续性的重要性;他们建议,乾眼症问卷应包括乾眼症状的时间过程、疼痛严重程度、以及神经病变性质。
  
  藉由简短、标准化的忧郁症和焦虑问卷,前台工作人员或技术人员可以简便且成本低地记录这些问题的答案,借以辨识可以从心理卫生保健咨询中获益的患者。
  
  研究作者结论指出,需要其它纵向研究来探讨一年以上乾眼症的特征,并评估哪里种疼痛管理策略(不论是全身性或局部)对于乾眼症患者最有帮助。
  
  从2013年10月1日至2015年4月30日,在迈阿密退伍军人医院采用前瞻方式纳入有广泛的特异性乾眼症状和征兆、但无明显的眼睑或角膜异常的120名患者,追踪一年期间的症状严重度变化。研究对象(平均年龄64 ± 11岁;109名男性)进行眼睛表面检查-包括泪膜评估和既有风险因素分析,以及在初诊和一年追踪就诊时进行5项乾眼问卷。
  
  排除标准是:配戴隐形眼镜、屈光手术、使用眼部药物(除了人工泪液)、活性外眼处理、过去6个月内进行白内障手术、任何青光眼或视网膜手术史、HIV、结节病、移植物抗宿主疾病、胶原血管疾病。
  
  一年时,没有、轻微或中度既有症状的58名研究对象中,有26人(44.8%)发展成更严重的症状,严重既有症状的62名患者中,有46人(74.2%)依旧有严重症状(「5项乾眼问卷」分数≧12)。
  
  预测一年时严重乾眼症状的因素是:更严重的乾眼症状、眼部疼痛,以及既有的神经性疼痛型眼部症状。其它风险因素是:睡眠障碍-包括睡眠呼吸暂停和失眠;精神病状态-包括创伤后压力异常和忧郁症;非眼部疼痛;药物(抗焦虑药和止痛药)。在之前的横断面研究中,这些非眼部风险因素也与乾眼有关。
  
  根据多变项分析,一年时严重乾眼症状的最显著风险因素是:睡眠呼吸暂停(胜算比[OR], 3.80; 95%信赖区间[CI], 1.00 - 14.49; P = .05)、「5项乾眼问卷」分数(OR, 1.15; 95% CI, 1.02 - 1.30; P = .02)以及创伤后压力异常分数(OR, 1.04; 95% CI, 1.01 - 1.08; P = .02)。
  
  研究作者结论指出,虽然研究世代仅限美国退伍军人,无法推论到其它族群,我们的结果认为,疼痛感知和严重程度在评估和治疗乾眼时很重要。
  
  其它研究限制包括:失去追踪、只有在初诊时进行眼部表面检查、在开始时和一年时之间缺乏期中评估。
  
  尽管有这些限制,研究者认为这些研究发现在生物学上是可信的,关于眼内的神经性疼痛,角膜伤害感受器接近眼睛表面,这些位置会被创伤、环境压力或泪膜异常等因素损坏。
  
  研究作者写道,反覆的压力会导致周边致敏化,随后可能导致中枢神经系统变化。
  
  睡眠呼吸暂停与眼睑松弛有关,眼睑松弛已被发现是严重眼表症状的危险因素,这或许是因为健康泪膜动力学受损的因素。心理健康状况可能会使个人易于疼痛、或者是疼痛的结果。
  
  资料来源:http://www.24drs.com/
  
  Native link:Persistent, Severe Dry Eye Linked to Pain, Nonocular Factors

Persistent, Severe Dry Eye Linked to Pain, Nonocular Factors

By Laurie Barclay, MD
Medscape Medical News

Researchers identified factors predicting severe dry eye symptoms 1 year after presentation in a longitudinal study published online December 22 in JAMA Ophthalmology. Although findings may not be generalizable to nonveteran populations, the investigators emphasize the importance of pain perception and severity to 1-year prognosis.

"[M]ost patients with severe baseline dry eye symptoms reported persistent severe symptoms at 1 year," write Erin S. Ong, BS, BA, from the Ophthalmology Department, Bruce W. Carter Department of Veteran Affairs, Miami Veterans Administration Medical Center, Florida, and colleagues. "Baseline nociceptive and neuropathic ocular pain, in addition to sleep disturbances, mental health status, nonocular pain, and medications were also risk factors."

Dry eye syndrome is highly prevalent, affecting millions of people. Although previous cross-sectional studies examined risk factors for dry eye severity, few looked at risk factors or symptom progression over time.

"This study highlights the important role of pain severity and perception on severity and persistence of dry eye," the authors write. They recommend that dry eye questionnaires include the time course of dry eye symptoms, pain severity, and neuropathic qualities.

Front desk staff or technicians could easily and inexpensively record answers to these questions, along with short, standardized questionnaires for depression and anxiety to identify patients who may benefit from mental health care consultation.

"Additional longitudinal studies are needed to characterize dry eye findings beyond 1 year and evaluate which pain management strategies, whether systemic or local, will be most beneficial in patients with dry eye," the study authors conclude.

Biologically Plausible Findings

From October 1, 2013, to April 30, 2015 at the Miami Veterans Affairs Hospital, 120 patients with a broad range of idiopathic dry eye symptoms and signs but no overt eyelid or corneal abnormalities were prospectively recruited and followed for changes in symptom severity over the course of 1 year. Participants (mean age, 64 ± 11 years; 109 men) underwent ocular surface examination including tear film assessment and baseline risk factor analysis, as well as Dry Eye Questionnaire 5 at their first and 1-year follow-up visit.

Exclusion criteria were contact lenses, refractive surgery, ocular medications except for artificial tears, active external ocular process, cataract surgery within the last 6 months, any history of glaucoma or retinal surgery, HIV, sarcoidosis, graft-versus-host disease, or collagen vascular disease.

At 1 year, 26 (44.8%) of 58 participants with no, mild, or moderate baseline symptoms developed more severe symptoms, whereas 46 (74.2%) of 62 patients with severe baseline symptoms continued to have severe symptoms (Dry Eye Questionnaire 5 score, ?12).

Factors predicting severe dry eye symptoms at 1 year were more severe dry eye symptoms, ocular pain, and neuropathic pain–like ocular symptoms at baseline. Other risk factors were sleep disturbances, including sleep apnea and insomnia; psychiatric conditions, including posttraumatic stress disorder and depression; nonocular pain; and medications (anxiolytics and analgesics). In previous cross-sectional studies, these nonocular risk factors were also linked to dry eye.

The most significant risk factors for severe dry eye symptoms at 1 year, according to multivariable analysis, were sleep apnea (odds ratio [OR], 3.80; 95% confidence interval [CI], 1.00 - 14.49; P = .05), Dry Eye Questionnaire 5 score (OR, 1.15; 95% CI, 1.02 - 1.30; P = .02), and posttraumatic stress disorder score (OR, 1.04; 95% CI, 1.01 - 1.08; P = .02).

"Although this cohort was limited to US veterans, which may not be generalizable to other populations, our results suggest that pain perception and severity are important when evaluating and managing dry eye," the study authors conclude.

Other study limitations include loss to follow-up, ocular surface examination only at initial visit, and lack of interim assessments between baseline and 1 year.

Despite these limitations, the investigators suggest that the findings are biologically plausible. Regarding neuropathic pain within the eye, the corneal nociceptors are near the ocular surface, where they can be damaged by trauma, environmental stress, or tear film abnormalities.

"Repeated stress can lead to peripheral sensitization, which may subsequently lead to changes in the central nervous system," the study authors write.

"Sleep apnea is associated with eyelid laxity, which has been found to be a risk factor for severe ocular surface symptoms, perhaps owing to disruption of the healthy tear film dynamic. Mental health conditions may either predispose individuals to pain or be a result of pain."

The Department of Veterans Affairs, National Institutes of Health, and Research to Prevent Blindness supported this study. The authors have disclosed no relevant financial relationships.

JAMA Ophthalmol. Published online December 22, 2016.

    
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