持續、嚴重的乾眼症與疼痛、非眼部因素有關


  【24drs.com】線上發表於12月22日JAMA眼科學期刊的一篇縱向研究中,研究者確認了預測一年後之乾眼症狀的因素。雖然研究結果可能不適用於非退伍軍人,研究者強調,疼痛感知和嚴重度對於一年預後的重要性。
  
  佛羅里達邁阿密退伍軍人醫學中心退伍軍人事務部Bruce W. Carter眼科部Erin S. Ong等人寫道,原本即有嚴重乾眼症狀的患者,大多數在一年時表示仍有持續的嚴重症狀。對於原本的疼痛性和神經性眼部疼痛,除了睡眠障礙、精神健康狀況,非眼部疼痛和藥物也是風險因素。
  
  乾眼症非常普遍,影響了數百萬人;雖然以前的橫斷面研究檢視了乾眼嚴重程度的風險因素,很少研究探討風險因素或症狀隨著時間的變化。
  
  作者們寫道,這篇研究強調了疼痛嚴重度和認知對於乾眼症之嚴重度與持續性的重要性;他們建議,乾眼症問卷應包括乾眼症狀的時間過程、疼痛嚴重程度、以及神經病變性質。
  
  藉由簡短、標準化的憂鬱症和焦慮問卷,前台工作人員或技術人員可以簡便且成本低地記錄這些問題的答案,藉以辨識可以從心理衛生保健諮詢中獲益的患者。
  
  研究作者結論指出,需要其他縱向研究來探討一年以上乾眼症的特徵,並評估哪種疼痛管理策略(不論是全身性或局部)對於乾眼症患者最有幫助。
  
  從2013年10月1日至2015年4月30日,在邁阿密退伍軍人醫院採用前瞻方式納入有廣泛的特異性乾眼症狀和徵兆、但無明顯的眼瞼或角膜異常的120名患者,追蹤一年期間的症狀嚴重度變化。研究對象(平均年齡64 ± 11歲;109名男性)進行眼睛表面檢查-包括淚膜評估和既有風險因素分析,以及在初診和一年追蹤就診時進行5項乾眼問卷。
  
  排除標準是:配戴隱形眼鏡、屈光手術、使用眼部藥物(除了人工淚液)、活性外眼處理、過去6個月內進行白內障手術、任何青光眼或視網膜手術史、HIV、結節病、移植物抗宿主疾病、膠原血管疾病。
  
  一年時,沒有、輕微或中度既有症狀的58名研究對象中,有26人(44.8%)發展成更嚴重的症狀,嚴重既有症狀的62名患者中,有46人(74.2%)依舊有嚴重症狀(「5項乾眼問卷」分數≧12)。
  
  預測一年時嚴重乾眼症狀的因素是:更嚴重的乾眼症狀、眼部疼痛,以及既有的神經性疼痛型眼部症狀。其他風險因素是:睡眠障礙-包括睡眠呼吸暫停和失眠;精神病狀態-包括創傷後壓力異常和憂鬱症;非眼部疼痛;藥物(抗焦慮藥和止痛藥)。在之前的橫斷面研究中,這些非眼部風險因素也與乾眼有關。
  
  根據多變項分析,一年時嚴重乾眼症狀的最顯著風險因素是:睡眠呼吸暫停(勝算比[OR], 3.80; 95%信賴區間[CI], 1.00 - 14.49; P = .05)、「5項乾眼問卷」分數(OR, 1.15; 95% CI, 1.02 - 1.30; P = .02)以及創傷後壓力異常分數(OR, 1.04; 95% CI, 1.01 - 1.08; P = .02)。
  
  研究作者結論指出,雖然研究世代僅限美國退伍軍人,無法推論到其他族群,我們的結果認為,疼痛感知和嚴重程度在評估和治療乾眼時很重要。
  
  其他研究限制包括:失去追蹤、只有在初診時進行眼部表面檢查、在開始時和一年時之間缺乏期中評估。
  
  儘管有這些限制,研究者認為這些研究發現在生物學上是可信的,關於眼內的神經性疼痛,角膜傷害感受器接近眼睛表面,這些位置會被創傷、環境壓力或淚膜異常等因素損壞。
  
  研究作者寫道,反覆的壓力會導致周邊致敏化,隨後可能導致中樞神經系統變化。
  
  睡眠呼吸暫停與眼瞼鬆弛有關,眼瞼鬆弛已被發現是嚴重眼表症狀的危險因素,這或許是因為健康淚膜動力學受損的因素。心理健康狀況可能會使個人易於疼痛、或者是疼痛的結果。
  
  資料來源: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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