MD Roundtable: Diagnosing and Treating Photophobia

Clinical Update EXTRA

CONTENT AVAILABLE NEURO-OPHTHALMOLOGY MD Roundtable: Diagnosing and Treating Photophobia

moderated by leah levi, md with kathleen b. digre, md, and randy h. kardon, md, phd

his article is part of an occa- Treatment Target sional series of MD Round- tables, in which a group of experts discuss a topic of interest in their field. This isT the second part of a conversation on photophobia, led by Leah Levi, MD, of the Scripps Clinic.1 She is joined by Kathleen B. Digre, MD, of the Univer- sity of Utah, and Randy H. Kardon, MD, PhD, of the University of Iowa. Following are edited excerpts from their conversation.

Diagnosis Dr. Levi: I think most of us have had situations in which photophobia pa- tients have a completely normal oph- thalmological examination. How do you approach these individuals? Aggressive treatment of dry eye may help alleviate photophobia symptoms. Dr. Digre: I can tell you that I have a structured approach. I first look at on your light sensitivity?” If that takes participating in the cause of their pho- the history and physical examination the sensitivity away, the condition tophobia. And if I don’t find anything and look for a central process. I really may be localized—dry eyes or corneal after that, I go back to the beginning delve into the history—as in, when did neuropathy or something like that. If and just go through that list again. this start, and what is their past medi- it doesn’t take it away, I also make sure It’s either something in the history or cal history? And they absolutely should that they aren’t actually complaining something on the exam. It should be be queried about previous migraine or of hemeralopia or nyctalopia and have approached just like we do with any migraine in the family. If the history some kind of retinal problems. other ophthalmic complaint. or physical exam suggests something Then, I look carefully at blinking— Dr. Kardon: I think Kathleen cov- central, then I might get neuroimaging and not just what you would see in ered all the bases on that. It’s similar to and consider other tests. Then, at the spontaneous blepharospasm but also what I go through. slit lamp, I look carefully for dry eyes. reflexive blepharospasm when a light is I do Schirmer testing. I look for shined in their eye. Treatment iritis, uveitis, and corneal staining. Do Finally, migraine is so common in a Dr. Levi: When you find an ocular they have underlying blepharitis? Do lot of these people; if I’ve got migraine cause, does giving treatment directed they have corneal erosion? You have to in the history with light sensitivity, at that underlying cause result in im- really be certain to look carefully. And sound sensitivity, odor sensitivity, provement of the symptoms—or are sometimes I’ll apply a topical anesthet- movement sensitivity, nausea, etcet- there some situations in which it really

jason s. calhoun, department of ophthalmology, mayo clinic jacksonville ic and ask, “What effect did that have era, I’m pretty sure that migraine is doesn’t?

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Readaptation to Light. Dr. Digre: some people, it is very helpful. Kathleen, you mentioned migraine Well, I would like to take your case I’ve had some luck treating some of medication. Now, for those patients (see under “A Challenging Case,” be- the pain associated with photophobia. who are not actually getting migraine low). As soon as these people go into Amitriptyline treats migraine; it’s a headaches currently but have chronic the dark, you’ve got a problem, because very good medication, even at low photophobia, are medications used for they become dark adapted all the time. doses. I’ve also had some luck with migraine prophylaxis effective? People just keep closing more shades, gabapentin for pain. And then there’s Dr. Digre: Some of them. In post- closing more windows, and shutting onabotulinum toxin [Botox]; we’ve traumatic photophobia patients, the themselves off from light. They even seen it help several people whose main anti-migraine drugs might be helpful, remove LEDs from the clocks in their complaint is photophobia. and Botox may also be helpful. room. This is just going to make their Dr. Levi: Randy, you mentioned Dr. Levi: What are the most help- condition worse. It’s as though it low- blue-blocking glasses with orange tint.1 ful migraine prophylactic medications ers their thresholds to the point where Is that more effective than the FL-41 for photophobia? You’ve already men- even the slightest light gives them pain. tint? How do you advise patients on tioned amitriptyline and gabapentin. They really have to get back into the which tint they might want to use? Are any others effective? light, open up the shades, and start Dr. Kardon: Well, the blue-blocking Dr. Digre: All of the migraine med- getting into brighter light, and they lens is the same one Kathleen men- ications might be effective. We have no will adapt eventually. They should tioned. Some patients have access to way of knowing which one is best for wear sunglasses outside. Just regular lenses that are found in sporting goods each individual. sunglasses are fine, even some wrap- stores. Hunters use them; they’re or- Treating Anxiety. Dr. Digre: I do around sunglasses. They should not be ange. These are similar to, I believe, want to mention that we have found wearing dark sunglasses inside. what she has been using. There are that some people with chronic pho- Dr. Levi: How slowly should they small differences [between the lenses], tophobia also can have underlying do this readaptation to light? Are you but they’re worth trying. As she indi- depression and anxiety—especially talking about days or weeks? cated, it provides some relief to some anxiety. And treating that, if they have Dr. Digre: As quickly as they can— patients. It’s not a universal treatment it, is also really helpful. the longer they’re in the dark, the effect that patients are always satisfied Dr. Levi: That’s a good point be- worse it gets. They have to realize that with, but every little bit helps. cause often migraine has a stress trig- and tolerate a little discomfort as they Novel Contact Lens. Dr. Kardon: ger, and I’m sure that being anxious start getting more into the light. Then [Researchers from] Syracuse reported and depressed about the symptoms they’ll be able to tolerate more and at ARVO 2 years ago that they were us- doesn’t really help. more light as time goes on. ing the soft contact lenses with an ar- Dr. Digre: Both anxiety and de- The real beauty of coming up with tificial pupil where the back of the iris pression have a physiologic basis in a diagnosis of photophobia is that if is opaque, not just tinted.3 These were the brain, and this may contribute [to you can tease out the cause, then you developed for aniridia patients, and photophobia]—and it’s been shown have something you can go after. So, if there’s a 4-millimeter opening in the sometimes in laboratory animals that they have bad dry eyes, you really need contact lens that limits peripheral light stress exaggerates painful responses. to work on that problem. If they’ve got coming in. The downside is that it does CGRP Research. Dr. Levi: Again, underlying migraines, those migraines obstruct some peripheral vision, but on the migraine issue: Randy, you had need to be treated. If they have blepha- the group of patients they tested expe- mentioned calcitonin gene–related rospasm, they need to have the blepha- rienced a significant amount of relief peptide (CGRP).1 Are any medications rospasm treated. from wearing those lenses. So that’s antagonistic to that available? Tinted Lenses and Pain Relief. another potential option. I haven’t Dr. Kardon: Not yet. There were Dr. Levi: Are dark glasses relatively tried them in very many patients yet. some phase 3 trials of antagonists of counterproductive in your experience? Pilocarpine. Dr. Levi: Have you CGRP, but because of some liver toxic- Dr. Digre: Outside, they’re appro- tried pilocarpine drops with patients ity in a small number of patients, that priate. Inside, they aren’t. There are with the same kind of thing in mind? drug development has stopped. Some tinted lenses that do work for some Dr. Kardon: This same group tried companies are developing antibodies people. This isn’t a panacea, but the pilocarpine drops, which had some ef- to CGRP that are injected. The idea is one we have been using is called FL-41 fect but not as much as a contact lens. that this could last for more than a few tint. This was first mentioned 30 or As I noted earlier,1 if you have a lightly weeks, and it might somehow modify 40 years ago by a group in England, pigmented iris, even constricting the CGRP-mediated migraine and pos- and it was formulated for people with the pupil pharmacologically to a mi- sibly photosensitivity, but this is not fluorescent light sensitivity. It seems otic state doesn’t adequately limit the yet available for clinical use. to block certain wavelengths of light— amount of light getting to the retina. Superior Sympathetic Blocks. around 480 nanometers—and for Migraine Prophylaxis. Dr. Levi: Dr. Levi: Kathleen, you’ve also pub-

26 december 2015 Neuro-Ophthalmology lished about people who have severe type of lens might be helpful. There pain and photophobia actually can photosensitivity and pain syndrome. are Internet sources for these lenses, make you a bit desperate. I’m sure that this isn’t very common, but make sure that the lens blocks the Dr. Digre: And the anxiety is proba- but [you cited cases] where a superior blue-light spectrum. Sometimes the bly part of the pathophysiology. I didn’t cervical ganglion block has been effec- makers say they do, but they really want to get into the animal studies, tive.2 Is that applicable to people who don’t. I’d maximally treat the dry eyes, but there’s one done by Andrew Ahn have extreme photophobia and noth- maybe with lubrication at night and and his colleagues in newborn rodents. ing has really alleviated it? tears during the day, and then I’d work Newborn rodents don’t have vision, but Dr. Digre: Many of the cases we on migraine prevention. I’d push up they do have active melanopsin cells, had looked like complex regional pain the migraine prevention so that the so they can sense light. These animals syndrome. They had an injury to their headache portion of this is completely were put into light, and they started cornea, and the injury healed, but they under control. squealing just like they do when they developed this kind of reverberat- Dr. Kardon: I would try to find out are taken away from their mother. It ing circuit of light sensitivity to just if the convergence insufficiency is re- is an anxiety response. Then the re- normal light. And then we did some ally part of the syndrome. Usually, I searchers looked at the brains of these superior sympathetic blocks with an do that by having them patch one eye animals and saw that the amygdala and anesthesiologist, they had relief of to verify whether it improves their several of the emotional centers were this symptom. So, I put this in my symptoms. In addition, if the patient triggered.4 If animals can have stress armamentarium. It’s a little bit more does have dry eyes, I have a low thresh- and anxiety related to light, this is a invasive, so it’s not my first-line, go-to old for putting in punctal plugs, since real deal. This anxiety component is an treatment, but I think when people it’s a pretty benign procedure. A lot of important one. ■ have a history of some kind of injury patients just don’t put in enough drops or corneal injury, maybe [they de- during the day to make a difference, 1 See “MD Roundtable: Solving the Photo- velop] reflex blepharospasm with this and I think silicone punctal plugs are a phobia Puzzle” in the November 2015 issue, injury or they haven’t responded to pretty easy way of really trying to miti- at www.eyenet.org. less-invasive treatments, I think that gate that part of the equation. 2 Fine PG, Digre KB. J Neuroophthalmol. the cervical sympathetic block defi- Dr. Digre: I totally agree. 1995;15(2):90-94. nitely can be offered. We still do it in 3 Jackowiski MM, Motter B. Poster 5307- certain cases. They Aren’t Crazy D0068 presented at: Association for Research Dr. Levi: I’m sure that this is a very Dr. Levi: Do either of you have any fi- in Vision and Ophthalmology Annual Meet- uncommon situation, but I’m sure nal comments? ing; May 8, 2013; Seattle. there are ophthalmologists out there Dr. Digre: I would just like to say 4 Delwig A et al. PLoS One. 2012;7(9):e43787. where this has happened to one of that ophthalmologists need to own doi:10.1371/journal.pone.0043787. their patients after even routine cata- photophobia as an eye complaint. ract surgery or LASIK. This is a problem that we all need to Dr. Digre is professor of ophthalmology and Dr. Digre: That’s right. be able to evaluate and treat, and we visual sciences and neurology at the John A. can’t just say, “Oh, well, I don’t see Moran Eye Center at the University of Utah in A Challenging Case anything wrong. It’s not your eyes; see Salt Lake City. Relevant financial disclosures: Dr. Levi: Back to my patient. She was somebody else.” I think that’s where Is a coinventor, with a patent pending, on a truly a challenge. She has dry eye. She people like your patient are just go- lens technology; she received less than $100, has convergence insufficiency, which ing in circles, seeing one doctor after which was given to the ophthalmology depart- is in turn a partial trigger for her mi- another. An ophthalmologist may ment at Moran Eye Center. graines. She has extreme light sensitiv- want to partner with a neurologist or Dr. Kardon is professor of ophthalmology and ity. She is more tolerant of lights now a headache specialist to try to get the visual sciences and director of the Neuro-oph- that she’s on migraine prophylaxis, but headache component under control, thalmology Service at the University of Iowa she still has problems with computer but we ophthalmologists really need in Iowa City. Relevant financial disclosures: screens to the extent that she can’t even to first own this symptom as real, then Department of Defense TATRC: S; MedFace: do her convergence exercises, which come up with the right diagnosis, and O; National Eye Institute: S; Novartis: C; Vet- are computer-based. then suggest plausible treatment. erans Administration: S. At this point, what suggestions Dr. Kardon: I couldn’t agree more. Dr. Levi is director of neuro-ophthalmology would you have? Dr. Digre: To refer back to your pa- at Scripps Clinic in La Jolla, Calif. Relevant Dr. Digre: I would start with some tient, that’s exactly the kind of patient financial disclosures: None. pencil push-ups and not use the com- I get sent all the time. Nobody’s taking See the disclosure key, page 8. puter for convergence exercises, as it’s them seriously. a trigger from the light point of view. Dr. Levi: A lot of these patients are EXTRA MORE ONLINE. For additional com- I think trying an FL-41 or a similar just blown off as being “crazy.” And ments, view this article online at www.eyenet.org.

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