More on Pain- and ways to control it.

Though the focus of my practice – and therefore, these posts – is on the eyes, much of what this blog series will capture, can often be generalized to other parts of the body and other “kinds” of pain. Dr. Huberman remains a key source of this information and my earlier post on pain references his excellent podcasts on this subject. I also draw from my years of practice and basic foundational teachings to “round out” and complement the referenced podcasts. Because each patient is different and the pain they bear is an amalgam of their perceptions and beliefs, this post is meant to give foundational information that may or may not be relative to any given patient and their disease state – so working with a good dry eye doctor (and possibly a good pain specialist) is important.

As I discussed in the last post, pain and inflammation are related (and necessary) – but particularly regarding the eye, control of inflammation is often essential in avoiding scarring and inflammation-related damage that can compromise the function of the eye. Anti-inflammation is at the heart of many dry eye related therapies, as chronic inflammation is bad and dry eye disease is typically chronic in nature. As to which comes first – the inflammation or the dryness – appears to vary, but the result is a “vicious cycle” that perpetuates both the inflammation and the dryness as one feeds off the other. I’ve posted substantially on these topics, but for clarity’s sake, I’ll provide a thumbnail version as this helps lead a conversation about control.

 A key concept in understanding dry eye, is understanding the many basic facets that can provoke it. Probably the most common cause I see appears to relate to lifestyle. Staring at screens (as these posts can incite – sorry, but it can affect me while writing them, too), causes the “Ocular Heart Attack” I’ve posted on before. Suffice it to say, keeping eyes open is an open invite to evaporation – and the longer one stares, the more likely the oil layer will separate, and the water will begin to leave, as it moves off into the drier air. These “dry spots” uncover the nerves in the clear window (cornea) and the cooling induced by evaporation together with the stimulation of these now “raw” nerves, will trigger reflex tearing (the “firehose” of salty water) and a blink. “Top down” control from the brain may reign in the strength and completeness of that blink in an effort “not to miss anything” – so weak, irregular blinking (like a weak, irregular heartbeat) causes poor replacement of the “Sprinkler system salad dressing” and the salt-watery “Emergency backup tear” begins to dilute the wholesome “salad dressing” tear – provoking inflammatory damage of that delicate surface layer.

 Add to that, the oil glands in the lids are becoming dormant – in part from the poor nutrition common to the modern “American” diet, and in part from the lack of exercise provided by the big, strong blinks experienced when outside actively “hunting and gathering,” as our great ancestors did – (because we generally spend too much time indoors staring at these screens) – and one can begin to see how “fixing” this problem may include nutritional support, active exercise and “retraining” our minds by developing better “blink habits.” Without enough “good oil” in the tear’s “salad dressing” recipie, evaporation will happen faster and the damage from that will lead to higher levels of inflammation and then more dryness.

 A second continuation of inflammation can then ensue as the dormant oil glands go on to house increasingly rancid, nasty oils as germs begin to set up housekeeping along the lid margins and amongst the openings to the glands, lashes and skin margins where good cleaning can be a challenge. Germs feasting on these oily products commonly contain lipases – enzymes that break the oils down into digestible “bites” and whose initial byproducts contain soaps (seen as little white “bubbles” along the lid margins) and then subsequent byproducts of their digestion (endo and exotoxins) are a strong bugle call to the body’s defense system – also known as inflammation! Soaps cut through the remaining oils – so evaporation becomes even more excessive – and these germs incite a riot from the body’s defenses, adding to the redness and then dryness.

 For dry eye-specific pain, this brings us to the commonsense approach of eating a healthy diet rich in essential Omega oils, drinking more water (and less of the things that dry us out, like caffeine and alcohol), spending more time outside in unpolluted “nature,” where we can exercise our lids with better blinking and then good lid hygiene (all of these covered in earlier posts). What is significant and perhaps under-appreciated, is that good, full-body exercise (anything from vigorous walking, to jogging, running, biking, etc) has added benefits in handling pain. Huberman advocates zone 2 cardio exercise 3-5 times per week (assuming this exercise is not aggravating an injury and doesn’t go against their doctor’s advice), along with getting 8-hours of sleep (or resting) per night. Additionally, he points to the “glymphatic system” as the “washing through” process of clearing debris out between the ends of neurons (the brain’s “wires”) which helps restore healthy brain function, and he notes work discovering that sleeping on one’s side (so not the back or belly) also helps in the efficiency of this “sewer system” of the brain.

 Perhaps more intuitive, he points to research showing that person’s “in love” – especially in longer or stronger relationships, have higher tolerances to pain. The “high” from loving emotions, like the rush from adrenaline, each contribute to the ability to withstand severe levels of personal harm, which would cause higher levels of pain – yet are “less perceived” under these circumstances. We all hear stories of a loved one’s comforting presence relieving pain better than strong medications – or wartime injuries where the soldiers carry on – sometimes for extended periods, with Herculean levels of activity after grave injuries – and may not appreciate the degree or extent of those injuries while performing those duties. Mystics and Monks who lean into religion or go into trance-like states may similarly endure severe pain while in those states. Our bodies appear to be “programmable” – likely a mix of the neural plasticity referred to in my earlier post, as well as the body’s chemistry - surging hormones and specific chemicals or “neural transmitters,” which alter our perceptions and energize us in times of severe pain and related stress. My next post will spend more time investigating what some of these responses can be and how we may modify them to better suite our personal perceptions of pain.