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Rocha de Lossada, M. Rodríguez Calvo de Mora, C. Hernando Ayala, D. Borroni" "autores" => array:4 [ 0 => array:4 [ "nombre" => "C." "apellidos" => "Rocha de Lossada" "email" => array:1 [ 0 => "carlosrochadelossada5@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Rodríguez Calvo de Mora" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "C." "apellidos" => "Hernando Ayala" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "D." "apellidos" => "Borroni" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Oftalmología, Hospital Regional Universitario de Málaga, Málaga, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Doctoral Studies, Riga Stradins University, Latvia" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Royal Liverpool University Hospital, Liverpool, UK" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fotofobia y dolor neuropático en el síndrome de Sudeck" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Sudeck's syndrome<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–3</span></a> is a neuropathic/inflammatory disorder characterized by<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–3</span></a>: severe pain extending beyond the injured area and disproportionate in relation to the initial event, autonomous deregulation with sympathetic system hyperactivity, neuropathic edema, motor disorders, atrophy and/or dystrophy.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Sudeck's syndrome does not have a defined origin, although even minor traumatisms are the most common cause (50%). In 25% of cases, the cause is unknown.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–3</span></a> The development of the disease does not appear to relate to the magnitude of the damages. For unknown reasons, the sympathetic system remains hyperactive after the injury.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,3</span></a> Initially, symptoms are centered in the area of the lesion but, if not treated adequately, could generalize<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2</span></a> producing varied and diffuse symptoms. There is no specific diagnostic test, making this syndrome an exclusion diagnostic. Early diagnostic is crucial to avoid possible subsequent complications.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The case of a patient diagnosed with Sudeck's syndrome is presented. The patient exhibited intense and disabling photophobia as well as ocular neuropathic pain.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinic case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 14-year-old patient diagnosed by pediatric rheumatology with Sudeck's syndrome after foot traumatism 3 years earlier after an exclusion diagnostic due to the inability to find another cause. The foot injury disappeared but the pain remained and worsened after banal stimuli and also extended to other limbs. Two years after debut, the patient exhibited progressive visual acuity deterioration associated to intense photophobia, for which reason the patient was referred to the authors’ practice. The patient was being followed up by Rheumatology, Rehabilitation, Pain Unit and Pediatric Psychiatry.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Ophthalmological examination produced best corrected visual acuity of 0.6 (Snellen), with refraction being +0.50 in both eyes. The rest of tests were not relevant: maximum stereopsis in the TNO test, normally reactive pupils to light and accommodation, and normal, painless ocular movements. The cover test was normal for near and far. Biomicroscopy produced anterior pole examination and funduscopy without relevant pathological findings, even though the examination was very difficult due to the intensity of the patient's photophobia and pain. The Schirmer test and tear breakup time (BUT) were within normal limits. Instillation of anesthetic eyedrops did not lessen pain and photophobia.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Campimetry, optical coherence tomography (OCT), retinal and macular nerve fiber layer thickness (RNFL), visual evoked potentials (VEP) and electrorretinograph (ERG) of both eyes, as well as cerebral nuclear magnetic resonance (NMR) were all compatible with normal values. The Neurology Dept. did not report pathological findings that could explain diminished vision or photophobia, for instance trigeminal neuralgia or cluster headache.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In subsequent visits, the patient reported intense photophobia and pain in both eyes that required the use of sunglasses even in closed rooms. All ocular examinations did not produce relevant findings other than the intense photophobia and ocular pain which did not respond to the administration of topical anesthetics.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">Neuropathic pain is defined as “pain initiated or caused by a primary lesion or dysfunction of the nervous system”<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> which could occur in the cornea due to being the most highly innervated structure of the human body<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> as well as due to compromise of other ocular structures. Neuropathic pain courses with pain, ocular irritation, feeling of dryness and photophobia.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5–10</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Sudeck's syndrome is an idiopathic neuropathic disorder<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–3</span></a> in which, after a lesion, generally a traumatism (in the present case a foot traumatism), a hyperactive and disproportionate response of the sympathetic system is triggered which in turn gives rise to an exaggerated response to pain, which could become generalized and compromise other structures of the body. In the present case, the generalization of pain gave rise to very intense photophobia and ocular neuropathic pain, which could even be the cause of the visual impairment exhibited by the patient.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Photophobia can be defined as abnormal intolerance to light.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5–7</span></a> Ophthalmology comprises multiple diseases that could course with photophobia including dry eye, conjunctivitis, uveitis, episcleritis, the use of some ocular medicaments and cataract or refractive surgery. Patients exhibit increased sensitivity to light in situations in which other individuals would not even though ophthalmological examination produces normal results, and generally seek places with low lighting and visit the ophthalmology practice wearing sunglasses, as in the case of the present patient.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5,7</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">When clinic symptoms are disproportionate to clinic signs on the ocular surface, neurosensory anomalies should be suspected. Recently, a new subcategory has been proposed for dry eye diagnostic, i.e., “neuropathic dry eye”, when symptoms are not proportionate to clinic signs.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,6,9,10</span></a> Said symptoms could worsen in circumstances that increase anxiety levels, produce depression or post-traumatic stress.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,6,10</span></a> In advanced stages of Sudeck's syndrome, psychological and psychiatric disorders could arise which could completely invalidate the patient.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> The present patient was in follow-up by Pediatric Psychiatry due to anxiety and depression, conditions which could be included in the differential diagnostic for the cause of pain. However, as mentioned above, it could also correlate with Sudeck's syndrome, thus exacerbating the disabling pain suffered by the patient.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Neuropathic ocular pain could be due to a range of local diseases such as dry eye, after cataract or refractive surgery, infectious keratitis, etc. or systemic diseases such as Sjögren syndrome, blepharospasm, migraine and fibromyalgia.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5,6,8,10</span></a> It has been demonstrated that patients with high neuropathic pain associate higher frequency of functional disorders, high non-ocular pain profile and even mental health problems.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Ocular nociceptive sensations travel through the first branch of the trigeminal nerve toward the trigeminal nuclear complex. After performing synapsis, neurons decussate and join the spinothalamic tracts to synapse in the thalamus. These nociceptive signals carry out an additional refinement in the subcortical areas before culminating the sensation of pain in the primary sensory cortex. The cornea is the structure of the body with the largest amount of nerve endings,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> although it is known that many ocular structures also comprise complex nerve endings such as the conjunctival, sclera, iris, ciliary body, choroids and retina.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,8</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Ocular nociceptors could undergo a plasticity process known as “peripheral sensitization” in which, due to tissue damage and ocular surface inflammation, pro-inflammatory mediators are released causing structural changes in the corneal nerves which diminish the pain threshold and intensify the peripheral pain signal. In time, said peripheral sensitization leads to “central sensitization” where the response of central nervous system neurons are disproportionate to the peripheral pain signals, which could course with photoalodynia, as could possibly occur in the present case.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,6,9,10</span></a> It has been proposed that said central sensitization is present in other pathologies such as fibromyalgia, irritable intestine syndrome or temporomandibular pain. Accordingly, many individuals who suffer some form of chronic pain frequently exhibit other, overlapping chronic pain disorders and could associate additional comorbidities such as mood disorder, sleep disorder and diminished quality of life.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">In order to differentiate between peripheral and central ocular neuropathic pain, a drop of topical anesthetic is administered and, if the pain diminishes, it could possibly have a peripheral origin whereas, if the pain does not diminish, the origin is probably central. In addition, a mixed component could be involved, in which symptoms improve after topical anesthetic but do not go away entirely.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,6,9</span></a> It has been demonstrated that patients who do not exhibit improvement of symptomatology with topical anesthesia associate increased cutaneous sensitivity to pain and higher discordance between symptoms and signs of the ocular surface when compared to those in which symptomatology improves after the application of anesthesia.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9,10</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The treatment of Sudeck's syndrome<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,4,8–10</span></a> is based on the rehabilitation of the impaired limb, analgesic measures and, in advanced cases, sympathetic blockages or sympathectomies. In ocular treatment, it is important to treat possible baseline diseases such as dry eye syndrome or Meibomium glands dysfunction with topical treatments such as preservative-free artificial tears, corticoids, cyclosporine, autologous serum, neuron growth factor, growth factor-rich plasma or platelet-rich plasma. In more advanced forms with central compromise symptoms, tricyclic antidepressants, anti-compulsives or opiates can be used, or alternatives such as acupuncture.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> A multidisciplinary management is required for managing said disease.</p><p id="par0085" class="elsevierStylePara elsevierViewall">In the view of the authors, Sudeck's syndrome could be included in the differential diagnostic of neuropathic ocular pain because it is a neuropathic disease whose main characteristic is an exaggerated response to pain after an initial injury event, the magnitude of which does not correlate with the severity of the symptoms experienced by patients.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0090" class="elsevierStylePara elsevierViewall">It is proposed that Sudeck's syndrome could be the cause of photophobia and ocular neuropathic pain that could give rise to significant alterations in the quality of life of patients, for which reason it should be included in the differential diagnostic of neuropathic ocular pain.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflict of interests</span><p id="par0095" class="elsevierStylePara elsevierViewall">No conflict of interests was declared by the authors.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1198463" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1116963" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1198462" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1116962" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinic case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-10-01" "fechaAceptado" => "2018-11-29" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1116963" "palabras" => array:4 [ 0 => "Sudeck's syndrome" 1 => "Neuropathic pain" 2 => "Photophobia" 3 => "Disproportionate pain" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1116962" "palabras" => array:4 [ 0 => "Síndrome Sudeck" 1 => "Dolor neuropático" 2 => "Fotofobia" 3 => "Dolor desproporcionado" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The case is presented of a 14 year-old patient diagnosed with Sudeck's syndrome secondary to uneventful foot trauma. The patient complained of decreased visual acuity along with photophobia and intense ocular pain not correlated with the exploratory findings.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Sudeck's syndrome is an idiopathic neuropathic inflammatory disease characterized by disproportionate pain, unrelated to a previous traumatic event, which can evolve to severe and generalized pain. A new explanation has recently been described this as “neuropathic eye pain” for those patients with severe eye pain that do not correlate with clinical signs. In the case presented here, the pain became widespread and led to photophobia and very intense ocular neuropathic pain. It is believed that this was the cause of the visual decrease that presented by this patient. It is proposed that the Sudeck syndrome should become part of the differential diagnosis of neuropathic eye pain.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Presentamos a un paciente de 14 años diagnosticado de síndrome de Sudeck secundario a traumatismo no complicado del pie, derivado a nuestro servicio por disminución de la agudeza visual junto con fotofobia y dolor ocular intenso no correlacionado con los hallazgos exploratorios.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El síndrome de Sudeck es una enfermedad inflamatoria neuropática idiopática caracterizada por un dolor que es desproporcionado al evento lesivo que lo origina y que puede generalizarse. Recientemente se ha descrito una nueva enfermedad, el dolor ocular neuropático, caracterizado por un dolor exagerado donde los signos clínicos no se correlacionan con el dolor. En nuestro caso al generalizarse el dolor, generó fotofobia y dolor neuropático ocular muy intenso, que creemos que puede ser la causa de la disminución visual que presenta nuestro paciente. Proponemos que el síndrome de Sudeck entre a formar parte del diagnóstico diferencial del dolor ocular neuropático.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Rocha de Lossada C, Rodríguez Calvo de Mora M, Hernando Ayala C, Borroni D. Fotofobia y dolor neuropático en el síndrome de Sudeck. Arch Soc Esp Oftalmol. 2019;94:293–296.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Síndrome de Sudeck (distrofia simpatico refleja)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "B. Fornos-Vieitez" 1 => "F.E. López-Díez" 2 => "A. Ciriza-Lasheras" 3 => "D. 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