Pain and the Glaucoma Patient
Chat Highlights
September 24, 2003

Norma Devine, Editor

On Wednesday, September 24, 2003, Dr. Elliot Werner, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Pain and the Glaucoma Patient."

Moderator:  Hello, Dr. Werner.  We're fortunate that weather-related problems didn't prevent you from being here tonight.  We will be discussing "Pain and the Glaucoma Patient."  

Dr. Elliot Werner:  Fortunately, electric power was restored this afternoon.  So I'm here and ready for the first question.

P:  Doctor, what is psychic pain?  Pain that is not actually there?

Dr. Elliot Werner:  Psychic pain is pain that results from emotional distress.  It is very real and is certainly there.  If anyone has had someone very close to them die, you know the meaning of psychic pain.  It is not imaginary.

Moderator:  Can psychic pain manifest itself as physical pain?

Dr. Elliot Werner:  Yes.  Who hasn't had cramps and stomach pain during periods of great fear?  Stage fright is a good example.

P:  Can someone diagnosed with glaucoma, or at different stages of the pain, suffer from psychic pain?  

Dr. Elliot Werner:  Several recent studies have shown that fear, depression, and anxiety about the diagnosis of glaucoma are common occurrences.  More patients in one study reported that fear was a worse symptom than loss of vision or other difficulties. 

P:  What can be done about that type of pain?

Dr. Elliot Werner:  That's a tough question for an ophthalmologist.  Depending on how severe it is, sometimes just reassurance and a good explanation of the patient's condition will help.  Some patients need psychiatric intervention to deal with their problems about having glaucoma or going blind.

P:  Before my trab (trabeculectomy), when I was having sub-acute attacks with closed-angle glaucoma, the pain was often accompanied by nausea.  Is that common?

Dr. Elliot Werner:  Yes, nausea and vomiting are prominent symptoms of angle-closure glaucoma, because of a reflex involving the pain nerve of the eye and the vagus nerve that controls the actions of the stomach and intestines.

P:  Does glaucoma itself cause physical pain, other than with acute-angle closure?  If the nerve is dying, I one wouldn't think that would be painful.

Dr. Elliot Werner:  That's a difficult question.  The eye does not have any nerves that "feel" the  IOP (intraocular pressure).  We cannot feel the pressure in our eye.  The pain that is felt in the presence of very high pressures seems to result from either inflammation or what is called ischemia, that is, an inadequate flow of blood.  In the absence of either inflammation or ischemia, the pressure can go very high without causing any pain.

P:  High IOP can cause pain in the eye, but how high, typically, will cause pain?  Does the size of the eye matter?  Can a larger eye withstand more eye pressure than a small (nanophthalmic) eye? 

Dr. Elliot Werner:  The intraocular pressure itself does not cause the pain.  Pain results only if the high pressure causes inflammation or interferes with the blood supply of the eye.  The level necessary to do that will vary from patient to patient.  I have seen people with intraocular pressure of 60 mm Hg and no pain and others who get pain if the pressure goes over 30 mm Hg.

P:  Can a trab cause chronic pain?

Dr. Elliot Werner:  Yes.  The bleb can interfere with the normal flow of the tears and cause discomfort.  Some people do seem to get a chronic pain after trabeculectomy that is difficult to explain.

P:  How do you distinguish between real pain and psychic pain? 

Dr. Elliot Werner:  Psychic pain is real pain.  It is not necessary to distinguish between them.  The question in any patient with pain is, what is the cause?

P:  Does the pain or discomfort trabs cause some people vary in severity and is it always present?  

Dr. Elliot Werner:  Everything in glaucoma varies from person to person.  Some people get a mild, intermittent discomfort.  Some people have moderately severe pain that can be constant or intermittent.  Some people have no pain at all.

P:  Is the pain in the upper part of the eye?

Dr. Elliot Werner:  Typically, the pain is at the site of the bleb.  Some people get a mild, chronic, smoldering inflammation of the eye after a trab that can cause a more generalized pain.  I had a hernia operation about eight years ago, and I still get pain in the incision from time to time.  Any surgery can produce long-term pain at the site of the operation.

P:  Is it common for fear after a diagnosis of glaucoma to help bring on an attack of shingles?

Dr. Elliot Werner:  I don't know, but stress can precipitate shingles in susceptible people.

P:  Glaucoma medications have caused my eye to be irritated and uncomfortable.  Can the drops cause pain?

Dr. Elliot Werner:  Glaucoma medications are probably the most common cause of pain in glaucoma patients.  Many of the eye drops seem to cause some discomfort, or even pain, as a side effect.  Unrecognized allergies to the medication can also be associated with eye inflammation and pain.

P:  Someone here (I think it was Dr. Wilson) once said that the pain from elevated IOP stemmed, not from the high pressure, per se, but from a rapid rise in the pressure.  Regardless of the mechanism that causes the pain, are there any qualitative aspects to pain from high IOP that distinguish it from other causes of eye pain, such as eye strain, brow ache, etc.?

Dr. Elliot Werner:  Not really.  We can usually tell by examination whether or not the pain is coming from high pressure, but not simply by what the patients tells us.  Dr. Wilson is right; he and I are saying the same thing.  Rapid increases in pressure are more likely to produce inflammation or ischemia and, therefore, pain.

P:  When I had pain from high pressure, I knew it.  My vision was blurred and the pain was unimaginable.

Dr. Elliot Werner:  Another cause of pain with high pressure is edema or swelling of the cornea.

P:  Would the same chronic pain apply to a shunt?  Sometimes I'll get an ache in my eye, but it usually doesn't last very long.

Dr. Elliot Werner:  Yes, many people with shunts have some degree of chronic or recurrent discomfort at the site of the operation.

P:  How does a glaucoma specialist deal with psychic pain?  What do you tell a patient?  I had to get psychiatric help, and was told I was "traumatized."  

Dr. Elliot Werner:  I try to ask such patients how they're doing and what they are feeling.  If they seem to be really suffering, and if fear, depression, or anxiety seem to be the cause, and I feel it is too severe for me to deal with easily, I usually suggest they see either their primary doctor or a psychiatrist.

P:  When I eat ice cream I get a sharp pain in my upper right eye.   Could that be damaging my eye or optic nerve?

Dr. Elliot Werner:  I get the same thing.  That is probably a form of migraine and is actually quite common.

P:  What can be done about pain from trabs or shunts?

Dr. Elliot Werner:  If any inflammation is present, it should be treated.  If the trab or shunt bleb is too large or in a bad position, sometimes surgical revision will help.  Sometime, mild pain killers like ibuprofen can help.

P:  Have you seen glaucoma patients who have pain from broken blood vessels in the eye (no trauma to the eye) to the point that the white of the eye is covered with blood?  Or could that be unrelated to glaucoma?  

Dr. Elliot Werner:  You are probably describing a subconjunctival hemorrhage.  Most such hemorrhages are harmless and occasionally are associated with pain.  The have nothing to do with glaucoma.

P:  Does the number of surgeries increase the likelihood of having some degree of chronic eye pain?

Dr. Elliot Werner:  Probably, yes.  Repeated trauma (and all surgery is a form of trauma) to the eye, as to any other part of the body, is more likely to result in chronic pain.

P:  Can glaucoma meds (Cosopt and Lumigan) cause vertigo?  I have developed symptoms of Meniere's disease, but my tests were all normal.  I have had four attacks within the past year.

Dr. Elliot Werner:  Vertigo is a very unusual side effect.  It has been reported mainly with the timolol in the Cosopt.  The only way to find out for sure is to stop the Cosopt for a short period to see if it goes away.

P:  I was sent to a neuro-ophthalmologist for chronic eye pain.  Do you ever refer patients to neuro-ophthalmologists?  

Dr. Elliot Werner:  Yes, if I think there is likely to be some benefit, and if I am concerned the pain is neurogenic (resulting from a disorder of a nerve) in origin.  Did the consultation with the neuro-ophthalmologist help?

P:  Yes, he put me on Neurontin and it seems to help a great deal.  

Dr. Elliot Werner:  Then you probably had a neurogenic component to your pain.

P:  I'm scared out of my wits about this whole topic and what is being said here.  I started with an acute-angle closure attack after my first visit to a doctor.  Then I had surgery, and two trabs, both of which failed.  Pain is intermittent.  Now I'm learning here that pain may be chronic.  That is an unpleasant prospect for those of us facing additional surgery.  

Dr. Elliot Werner:  Being sick is never fun.  Many diseases that humans are subject to produce pain, sometimes chronic pain.  Most of the time, we can get the patient some relief, but sometimes we cannot get the pain to go away completely.  I don't blame you for being frightened and frustrated.  Nothing is more frustrating than pain.

P:  After my trab, I had pain everyday, at the same time.  It started when I used the computer at work.  Could the pain have been from staring at the computer screen?  I no longer have any pain.

Dr. Elliot Werner:  In the post-surgical period, the eye is always inflamed.  Any part of the body that is inflamed will hurt if you use it.  If you had an operation on your knee and went running a week or so later, your knee would hurt.  Same principle with the eye.

P:  Can lens implants cause eye pain?

Dr. Elliot Werner:  Rarely.  Posterior chamber lenses hardly ever cause pain.  Some anterior chamber lenses seem to cause chronic discomfort and tenderness.  More likely, if an implant patient has pain it is due to inflammation, rather than the lens implant itself.

P:  Dr. Werner, you've been candid.  It's better if you know what you are facing than to wonder if something is wrong with you.

Dr. Elliot Werner:  It has been my experience that, with proper care, things often get better with time, but it can take some time and often requires patients to have patience.

End of highlights for September 24, 2003.

On October 1, Dr. Wilson discussed "The Newly Diagnosed Patient" in the Chat room. Click here for highlights of that meeting.

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