My Experience Treating Patients with Visually Induced Trigeminal Dysphoria

My experience treating trigeminal dysphoria began in 2018 during my mentorship with Paul Karpecki, OD, FAAO, and Jeffrey P. Krall, OD. The evolving, shared philosophy and protocol for preventing, treating, and managing ocular surface disease includes analysis for the presence of biofilm, inflammation, meibomian gland obstruction, and tear film toxicity affecting the structure and function of ocular physiology.¹ The mindset when treating these four categories continues to prove most successful when analyzed as a whole system, avoiding the less than ideal thought to delineate these categories and treat individually. A new concept worthy of inclusion in the paradigm: trigeminal dysphoria.^2,3,4 Trigeminal dysphoria is a condition that triggers “dry eye like” symptoms referred to as “phantom dry eye, or pseudo dry eye.” Thought to be caused by an underlying eye misalignment, it is now understood that trigeminal dysphoria elicits similar symptoms and presents like our more formal definition of ocular surface disease.^3,5

Research has shown that the trigeminal nerve, in addition to responding to corneal sensitivity and answering the question, “How do my eyes feel?” also exhibits a response to proprioceptive cues and awareness of alignment or misalignment between the eyes eliciting the response, “When my eyes are pointing here, how do they feel?”³ I was keenly aware of the neuromuscular responsibilities of the motor cranial nerves (CN) associated with eye movement (CN III, IV, V, VII, VIII),^3,6 and the vision performance difficulties and symptoms that occur when these unions fail to synchronize.³

However, I previously gave little credit to the sensory component of CN VI and its role in vision performance. Since my mentorship, I now understand how deeply the sensory fibers of the trigeminal nerve descend into the neck and shoulders. The compensatory neck and head movement required to stabilize our eyes and compensate for the underlying eye misalignment we postulate is the causation of the hypersensitization of the ophthalmic branch of CNV.³

At times, the whole trigeminal complex becomes up-regulated and the patient experiences global symptoms that may be described as headaches, jaw ache, neck tension, dizziness, dry eye, and light sensitivity.^5,7

Eyestrain is a common condition that occurs when eyes become tired from intense use, such as while driving long distances, staring at computer screens and other digital devices, or reading without pausing to rest the eyes.⁸ According to the Vision Council, the symptoms of digital eye strain, listed by increasing prevalence, include eyestrain, dry eyes, headaches, blurred vision, and neck/shoulder pain when using digital devices, while reading, or doing detail work.⁹

About 80% of American adults report using digital devices for more than 2 hours per day, and nearly 67% use two or more devices simultaneously.⁹ Nearly 59% of this population report symptoms of digital eye strain.⁹

This percentage represents a larger group than the reported prevalence of dry eye disease, which ranges from 5 to 50%.¹⁰ Adding to this dilemma is the fact that the use of digital technology has increased rapidly since 2000 (Figure).^11-13 The functional capacity of our visual neurol-ogy either exceeds the expectation of a visually demanding lifestyle or symptoms occur from an unmet expectation.¹⁴ That’s the reason I believe the lifestyle index, a detailed patient questionnaire created by the experts who pioneered the contoured prism lenses, is so effective.²

In my experience, using the questionnaire has opened a neutral platform for focused conversations with patients who may never thought to mention eye strain and headaches to their eye care provider. Twelve months ago, I made the decision to include this technology to our menu of diagnostics. Since then, we have noted streamlined clinic flow, more efficient differentials, and have experienced some of my favorite clinical memories as we offer relief to patients in this capacity.

The likely candidate for contoured prism has a positive cover test, normal osmolarity scores, and positive lifestyle index results. In my practice, all adults older than 18 years who score positive on their questionnaire will experience the measurement technology to identify a potential underlying eye misalignment. Based on results from the on chair-side refraction combined with objective data from the measurement device, custom contoured lenses are prescribed. We repeat an objective and subjective analysis 3 weeks after the therapeutic lenses have been revealed to the patient. Most often we clinically note reduction of their misalignment and subjectively measure reduction of their symptoms.¹⁵

I find this technology especially helpful for our adult head and brain injury survivors.

Prism lenses are not indicated for patients with hyperopia is greater than +6. 00 D, myopia greater than -9.00 D of SE correction at distance, or BCVA of 20/80 or worse in either eye. Additional contraindications for this technology include severe strabismus or palsy resulting in greater than 10 prism D of misalignment in one eye; greater than 20.00 D of eye misalignment; or greater than 4.00 D of astigmatism in either eye. This measurement device and therapy is also not meant for patients with physical tremors or muscle spasms that prevent sitting still.¹⁵ However, the therapeutic lens technology may be utilized by other means for this group of patients.¹⁵

PEDIATRIC PATIENTS

The culture of my practice shares a preventive mindset with our patient base. We have many pediatric patients in our ocular surface disease program, and we are always on the lookout for vision concerns that may affect future success in academics and athletic performance. The Vision Council reported that more than 70% of American adults claim their children experience the following symptoms after being exposed to 2 or more hours of screen time: headaches (8.8%); neck/shoulder pain (5%); eye strain, dry or irritated eyes (9.1%); reduced attention span (15.2%); poor behavior (13.3%); and irritability (13.5%).¹¹

We educate parents on the risk factors, and my team performs an alignment analysis and lifestyle index survey on every patient younger than 18 years. This alignment analysis is especially helpful for children who complain of headaches and those who are showing signs of avoidance of visual tasks. It is a wonderful feeling to offer parents a noninvasive, drug-fee solution to their children’s headaches and related problems such as digital eye strain.³

Conclusion

Just as we analyze the structure and function of a patient’s meibomian glands, or the structure and function of an optic nerve with retinal imaging and electroretinogram technology, my clinic has seen the benefits of objectively measuring and treating eye misalignment in a new functional capacity.

In our practice, patients often report spending thousands of dollars out of their pocket each year to reduce their symptoms of dry eye, headaches and neck/shoulder pain. They have utilized other treatments, including massage, chiropractic care, nerve blocks, and acupuncture—each of these supportive ancillary treatments are helpful, but reduce only the symptoms rather than the cause. Patients report that their symptoms return within 2 to 3 days after the ancillary treatments are offered. In my practice, this misalignment technology allows us to arrive at a potential root cause solution in patients with dry eye like symptoms caused by trigeminal dysphoria.³

Unmet visual neurology demands produce unspoken symptoms, and we have found in our practice that many patients do not always know to share these symptoms with us. I anticipate the incidence of reporting these symptoms related to trigeminal dysphoria will increase as further education, prevention, and knowledge is promoted. With access to this measurement and lens technology, now more than ever, we are able to approach this specific problem with a preventive mindset and eduate patients and providers regarding the effects of the digital demands in their life and how to combat the symptoms.¹²