Misdiagnosis and Missed Diagnosis

For reasons we cannot explain, some co-morbidities associated with Dry Eye Syndrome are often misdiagnosed or missed altogether. Conjunctivochalasis, for example, is a condition that can be extremely debilitating. When symptomatic, it is sometimes misdiagnosed as ocular neuropathy or corneal neuropathy. The less specific ocular neuropathy at least does not locate the condition on the cornea. (Conjunctivochalasis is loosening and wrinkling of the conjunctiva, the clear tissue that covers the white of the eye and the inside of the eye lids). Whereas corneal neuropathy, which means nothing more than pain of the corneal nerves, could be more specifically photophobia or a corneal abrasion or a blocked meibomian gland and even an eye lid spasm…. or something else.

A non-specific diagnosis e.g. ocular rosacea, blepharitis, ocular or corneal neuropathy, may be the best a doctor can come up with. But these general diagnoses are particularly problematic for patients because the treatment prescribed is not targeted to a specific disease.

The treatment prescribed for a non-specific diagnosis like blepharitis (warm compresses and lid wipes) may do nothing for demodex mites, obstructive meibomian gland dysfunction (MGD), or staphylococcus epidermidis, conditions that all contribute to blepharitis, inflammation of the eye lids.

The same goes for the general diagnosis “ocular neurapathy.” When anesthetizing pain medications or even autologous serum tears are the typically prescribed treatments it’s improbable that the patient will get long term relief. Not only is the underlying condition not addressed, because anesthetizing pain medications only mask the underlying condition, but serum tears may exacerbate symptoms by increasing the bacterial load harbored in the folds of the wrinkled conjunctiva.

Adding to the frustrating situation for patients, doctors may also have biases, as noted in the 2007 Report of the Dry Eye Workshop:

Bias of panelists’ selection may inevitably occur as a result of the inclusion criteria chosen. It is a common observation that highly published authors tend to have some form of commercial support from pharmaceutical industry. Nine of 17 panelists disclosed a past or present relationship as a speaker/consultant/research funds recipient from companies having products for the treatment of DTS (Dysfunctional Tear Syndrome – the term preferred by the Dry Eye Workshop group to describe Dry Eye Syndrome).

It’s not Psychosomatic. It’s a Misdiagnosis or Missed Diagnosis

Finally, we are alarmed at studies that conclude that eye pain associated with Dry Eye, but without a clinical manifestation or medical reason, can be attributed to psychosomatic illness (somatoform disorder or somatisation), like the one titled Prevalence and risk factors of dry eye disease in a British female cohort, published in the British Journal of Ophthalmology in September 2015. Or the one titled Ocular neuropathic pain from 2016 also published in the British Journal of Ophthalmology. For Dry Eye patients who live with debilitating pain every day, the notions that pain is “in their heads” or “due to overstimulated nerves” is extremely frustrating. These very intelligent doctors seem to be inventing new diseases to explain something they don’t know or understand.
And how will they then, having invented a psychosomatic disease of the nerves, propose that this new disease be treated. With Lyrica? With antidepressents? Let’s hope not.

Because we believe, like Dr. James Le Fanu explains in A Clutch of New Syndromes?, that just because a medical or physiological reason isn’t obvious doesn’t mean it’s not there. Thankfully some doctors acknowledge that unattributed eye pain should be further investigated. See:

The impact of conjunctivochalasis on dry eye symptoms and signs
Chhadva P, Alexander A, McClellan AL, McManus KT, Seiden B, Galor A.
Investigave Ophthalmology and Visual Science
2015 May 1
View the report