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Show Relief of Refractory Photo-Oculodynia With Botulinum Toxin We read with great interest the recent comprehensive review of photophobia by Digre and Brennan (1). The complex underlying mechanisms continue to be eluci-dated and treatment can be challenging. We have treated a patient with refractory photo-oculodynia and her case exemplifies these challenges. A 40-year-old woman lost left facial nerve function as a result of surgery for a vestibular schwannoma. She was assessed in the third postoperative week and found to have severe corneal epitheliopathy from exposure. A lateral tarsal pillar tarsorrhaphy was performed leading to improvement in the corneal appearance, but light sensitivity persisted. Over the next 6 months, sensitivity to light increased and the eye was increasingly painful. She was using hourly Lacri- Lube (Allergan, Inc) and patching overnight. Her anterior chamber was quiet and the cornea showed only a few punctate erosions. A medial tarsal pillar tarsorrhaphy was added, which improved her pain initially, but did not affect her light sensitivity. She began wearing dark glasses at all times, and FL41 filter was added 3 months later. She wore a baseball cap when outdoors. The patient described a constant aching pain that varied in intensity as well as distinct, intermittent sharp lancinating pains induced by light. At this point, her cornea did not show a single area of epithelial disruption. Patching improved her comfort level, so daily she would patch her eye closed at 6 pm. Over the following 2 years, numerous lubricating agents, oral medications, including gabapentin, pregabalin, carbama-zepine, and oxycodone, as well as acupuncture were tried without success. Botulinum toxin (58 units) was then injected subcutaneously over the frontalis, corrugator, pro-cerus, lateral canthus, and temple. Her refractory symptoms responded to these injections with an improvement in both light sensitivity and pain that lasted 8 weeks. She has received further injections and continues to respond to the same dose. Photo-oculodynia syndrome was first described by Fine and Digre in 1995 (2) to differentiate a category of idiopathic chronic eye pain accompanied by exquisite light hypersensitivity without signs of ocular inflammation. A history of ocular trauma, which may be minor, usually precedes the symptoms (2,3). Topical anesthesia and cycloplegia provide no relief (3). Fine and Digre (2) showed improvement with cervical sympathetic ganglion block in 6 patients with chronic symptoms, supporting the classifica-tion of photo-oculodynia as a sympathetically mediated pain syndrome. Shoari and Katz (3) used botulinum toxin in 2 patients with photo-oculodynia syndrome with good results. Botulinum toxin has now been shown to be effective in 3 patients with refractory photo-oculodynia. Although the evidence is limited, we would advocate for a controlled trial of botulinum toxin in patients with photo-oculodynia. Michel J. Belliveau, MD Department of Ophthalmology Queen's University Kingston, Ontario, Canada David R. Jordan, MD Department of Ophthalmology University of Ottawa Eye Institute The Ottawa Hospital Ottawa, Ontario, Canada REFERENCES 1. Digre KB, Brennan KC. Shedding light on photophobia. J Neuroophthalmol. 2012;32:68-81. 2. Fine PG, Digre KB. A controlled trial of regional sympatholysis in the treatment of photo-oculodynia syndrome. J Neuroophthalmol. 1995;15:90-94. 3. Shoari M, Katz BJ. Treatment of the photo-oculodynia syndrome with botulinum toxin A. Neuroophthalmology. 2007;31: 105-109. Belliveau and Jordan: J Neuro-Ophthalmol 2012; 32: 293-293 293 Letter to the Editor Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. |
