REDUCTION OF POSTINTRAVITREAL INJECTION PAIN USING ICE: An Open-Label Interventional Randomized Controlled Trial.

PURPOSE: Intravitreal injections of intraocular therapeutic agents are a common and effective treatment for various retinal pathologies. Patient discomfort related to injection is a potential barrier to treatment. Our aim in this study was to evaluate whether cooling the eye using topical ice compresses before intravitreal injection will reduce pain or bleeding. METHODS: This randomized controlled open-label study included 42 patients. All patients received a standard topical anesthesia protocol and then were randomly assigned to either receive a placement of ice packs (intervention group) or a room-temperature pack (control group) on the eyelid, 2 minutes before the intravitreal injection. Patients' discomfort, itching, burning and pain (using visual analog scale), and bleeding size (using photographs) were measured 1 and 10 minutes after the injection. Tolerability was calculated by averaging patients' discomfort, itching, burning, and pain scores. RESULTS: At 1 minute, pain (1.95 vs. 4.27, P = 0.01) and overall tolerability (1.66 vs. 2.98, P = 0.03) were significantly lower in patients receiving ice packs. At 10 minutes, pain (1.6 vs. 3.73, P = 0.02), burning (0.9 vs. 3.09, P = 0.007), discomfort (2.1 vs. 4.27, P = 0.008), and overall tolerability (1.23 vs. 2.87, P = 0.004) were all significantly lower in the ice group compared with the controls. Bleeding size (area or circumference) was not statistical different between groups. CONCLUSION: Topical ice patch administered before intravitreal injection significantly decreased pain and overall tolerability. This simple and inexpensive method may be used to ameliorated pain and improve tolerability.

Transcutaneous Electrical Nerve Stimulation for the Long-Term Treatment of Ocular Pain.

PURPOSE: Ocular pain is a debilitating condition that is challenging to treat as therapies that target the ocular surface are often ineffective. We previously reported a short-term reduction in ocular pain after one periocular transcutaneous electrical nerve stimulation (TENS) session. The current study aims to elucidate the long-term effect of TENS on ocular pain. MATERIALS AND METHODS: Fourteen individuals with eye pain were identified as candidates for a TENS device (RS Medical, Vancouver) for home use after a successful trial in clinic between February 2018 and July 2019 at the Miami Veterans Administration Hospital or University of Miami. Ten of the 14 patients were included in this retrospective review, based on the inclusion of receiving and using the device for a minimum of three months. The median age of the ten patients was 47.5 years, range 32-73 years, and eight were male. The main outcome measures were 1) frequency of long-term integration of TENS into ocular pain management and 2) patient reported ocular pain intensity (0-10) pre- vs. post-treatment. RESULTS: Patients reported an initial median use of the device 14.0 times per week and over time reducing the frequency to 3.0 times per week. All reported that the TENS unit was successfully incorporated into their ocular pain management routine for at least three months (median duration of use 6.5 months, range 3-14 months). Nine of ten patients reported subjective pain reduction with use of the TENS device at home. Overall, pain intensity decreased by approximately 27.4% (mean rank = 5.6, Z = -2.1, p = 0.02) post- vs. pre-treatment. No adverse events associated with TENS were reported in any patient. CONCLUSION: Our preliminary data suggest that TENS can be integrated into the long-term management of ocular pain with improvements in overall pain intensity.

Efficacy of Care for Blind Painful Eyes.

PURPOSE: Pain relief for a blind painful eye often follows an escalating paradigm of interventions. This study compares the efficacy of common interventions. METHODS: A retrospective chart review of blind painful eye cases was conducted at a single tertiary institution from April 2012 to December 2016. Demographics, etiology, treatment, and pain level were assessed. RESULTS: Among 99 blind painful eyes, 96 eyes initially received medical therapy (topical steroids, cycloplegics, and/or hypotensives), with pain relief in 39% of eyes. Minimally invasive interventions (laser cyclophotocoagulation, retrobulbar injection, or corneal electrocautery) were performed 41 times in 36 eyes, 34 of which had failed medical therapy, and led to pain relief in 75% of eyes. Evisceration or enucleation was performed in 28 eyes, and long-term pain relief was achieved in 100% of eyes. Surgery allowed discontinuation of oral analgesics in 100% of cases versus 20% for minimally invasive therapy (p = 0.005) and 14% for medical therapy (p = 0.0001). Compared with medical therapy, minimally invasive therapy was 2.5 times more likely to achieve lasting pain relief (p = 0.003) and surgical therapy 35.6 times more likely to achieve lasting pain relief (p = 0.011). High initial pain score was associated with nonsurgical treatment failure. CONCLUSIONS: Medical therapy provides pain relief in a moderate number of patients with a blind painful eye. When medical therapy fails, minimally invasive therapy and surgical interventions are successively more effective in relieving ocular pain. High initial pain score is a risk factor for nonsurgical therapy failure and may merit an earlier discussion of surgical intervention.

Eye Pain and Dry Eye in Patients with Fibromyalgia.

Objectives: The aim of this study was to examine visual function and eye symptoms in fibromyalgia patients, with a particular focus on dry eye syndrome and eye pain. Methods: A tertiary care center-based cross-sectional study was carried out in chronic musculoskeletal pain patients diagnosed with fibromyalgia. Chronic musculoskeletal pain patients without fibromyalgia were enrolled as a comparison group. Self-reported eye pain was investigated with the McGill pain questionnaire and the numeric rating scale. In addition, we assessed corrected visual acuity, vision-related quality of life, and self-reported dry eye syndrome. Results: A total of 90 musculoskeletal pain patients were included, with 66 patients fulfilling American College of Rheumatology 1990 criteria for fibromyalgia. Sixty-seven percent (95% confidence interval [CI] = 56%-78%) of the fibromyalgia patients reported eye pain, and 62% (95% CI = 43%-81%) of those were without fibromyalgia diagnosis. Sixty-seven percent (95% CI = 56%-78%) of the fibromyalgia patients reported an experience of dry eye compared with 76% (95% CI = 57%-95%) in the nonfibromyalgia group. Vision-related quality of life was noticeably reduced in both groups. Conclusions: Eye pain and dry eye are common in chronic pain patients, with comparable prevalence in musculoskeletal pain patients with and without fibromyalgia.

Comparison of the Lotrafilcon B and Comfilcon A Silicone Hydrogel Bandage Contact Lens on Postoperative Ocular Discomfort After Photorefractive Keratectomy.

OBJECTIVES: To compare the lotrafilcon B and comfilcon A silicone hydrogel bandage contact lenses after photorefractive keratectomy (PRK). METHODS: One hundred twenty eyes of 60 patients who underwent PRK were included in this randomized clinical trial study. In the end of the surgery, the lotrafilcon B (Air Optix; Ciba Vision, Duluth, GA) was used in one eye and the comfilcon A (Biofinity; Coopervision, Fairport, NY) was used in the fellow eye randomly. Pain and discomfort were assessed on the first and third day after surgery by visual analogue scale. RESULTS: The mean pain score was 3.75±3.32 and 4.47±3.60 on the first day (P=0.253) and 3.63±3.48 and 4.16±3.60 on the third day (P=0.416) after the use of the lotrafilcon B and comfilcon A, respectively. The results showed no significant difference between the two groups (P=0.823). The mean score of foreign body sensation was 4.31±3.38 and 5.49±3.04 on the first day (P=0.045) and 4.44±3.34 and 5.13±3.23 on the third day (P=0.250) after the use of the lotrafilcon B and comfilcon A, respectively. The comfilcon A lens caused a more severe foreign body sensation only on the first day. There was no significant difference in photophobia, epiphora, and blurred vision between the two lenses (P>0.05). CONCLUSIONS: Both lotrafilcon B and comfilcon A silicone hydrogel bandage contact lenses reduce clinical symptoms after PRK effectively. We found no difference in pain control and discomfort between them. However, the patients using the lotrafilcon B lens showed less foreign body sensation on the first day postoperatively.

Influence of a Therapeutic Soft Contact Lens on Epithelial Healing, Visual Recovery, Haze, and Pain After Photorefractive Keratectomy.

OBJECTIVES: To examine the influence of a therapeutic soft contact lens (TSCL) after alcohol-assisted photorefractive keratectomy (PRK) on visual recovery, epithelial closure, pain perception, and haze formation. METHODS: Prospective, randomized, single-center, contralateral eye, patient-masked study. Same surgeon treated 15 patients with bilateral PRK using a Vidaurri Fluid Retention Ring (Katena) with 8.7 mm inner diameter to apply ethanol 18% for 30 sec. Each patient received a TSCL (Balafilcon A, PureVision, Bausch & Lomb) in a randomized fashion in one eye only. RESULTS: Without knowing which eye had a contact lens, four patients preferred the eye with TSCL so much that these patients wanted a TSCL inserted in the second eye as well. Uncorrected distance visual acuity improved postoperatively from day 1 to 3 months from 0.61 to 1.18 with TSCL and from 0.21 to 1.04 without TSCL. Uncorrected distance visual acuity was statistically significantly better on days 1 and 2 with TSCL. Epithelial defect was on average smaller with TSCL. Epithelium was closed at day 4 in all eyes except one without TSCL. Pain perception was significantly lower with TSCL on days 1 and 2. Haze levels after 3 months were significantly lower with TSCL (with 0.09/without 0.45, respectively). One eye without TSCL had haze grade 2 (Fantes). CONCLUSIONS: A TSCL had statistically significantly and clinically meaningful beneficial effects in the first days in visual recovery and pain perception and after 3 months in haze formation. Epithelial healing was slightly quicker with the use of TSCLs (not statistically, but clinically significantly).

Noninvasive Electrical Stimulation for the Treatment of Chronic Ocular Pain and Photophobia.

INTRODUCTION: "Dry eye" or "keratoconjunctivitis sicca" is a multifactorial disease estimated to have a worldwide prevalence of 5-33%. Conventional therapies targeting the ocular surface with artificial tears, anti-inflammatories, punctal closure, eyelid hygiene, and antibiotics do not provide relief in all patients, especially those with neuropathic-like ocular complaints (wind hyperalgesia and photophobia). We anticipated that ocular transcutaneous electrical nerve stimulation (TENS) would alleviate symptoms of ocular pain, photophobia, and dryness in these latter individuals. METHODS: All individuals who received electrical stimulation between May 10, 2016 and April 6, 2017 for the treatment of chronic ocular pain at the oculofacial pain clinic of the Miami Veterans Administration Hospital were included in this retrospective review. All patients had symptoms of dryness along with other neuropathic-like symptoms (e.g., photophobia) and minimal signs of tear dysfunction. Ocular pain intensity, symptoms of dryness, and light sensitivity were compared pre-treatment and five min post-treatment via a two-tailed paired Student's t-test. RESULTS: The use of TENS significantly reduced the mean pain intensity in both the right and left eyes five min after treatment compared to prior to treatment (p < 0.05, paired t-test). The use of TENS significantly decreased light sensitivity in both eyes (p < 0.05). The findings for symptoms of dryness, however, were equivocal with a significant decrease in the left eye but not the right (p < 0.05, paired t-test). DISCUSSION: Our data indicate that TENS may similarly provide analgesia in patients with dry eye symptoms as it does for many other chronic pain conditions. Furthermore, the noted effect on symptoms of photophobia and dryness suggest that all may be linked by similar trigeminal-thalamic-cortical pathways. Prospective studies with electrical stimulation of dry eye are needed to further elucidate its benefit and mechanism of action.

Neuropathic Corneal Pain: Approaches for Management.

Neuropathic pain is caused by a primary lesion or dysfunction of the nervous system and can occur in the cornea. However, neuropathic corneal pain (NCP) is currently an ill-defined disease. Patients with NCP are extremely challenging to manage, and evidence-based clinical recommendations for the management of patients with NCP are scarce. The objectives of this review are to provide guidelines for diagnosis and treatment of patients with NCP and to summarize current evidence-based literature in this area. We performed a systematic literature search of all relevant publications between 1966 and 2017. Treatment recommendations are, in part, based on methodologically sound randomized controlled trials (RCTs), demonstrating superiority to placebo or relevant control treatments, and on the consistency of evidence, degree of efficacy, and safety. In addition, the recommendations include our own extensive experience in the management of these patients over the past decade. A comprehensive algorithm, based on clinical evaluation and complementary tests, is presented for diagnosis and subcategorization of patients with NCP. Recommended first-line topical treatments include neuroregenerative and anti-inflammatory agents, and first-line systemic pharmacotherapy includes tricyclic antidepressants and an anticonvulsant. Second-line oral treatments recommended include an opioid-antagonist and opiate analgesics. Complementary and alternative treatments, such as cardiovascular exercise, acupuncture, omega-3 fatty acid supplementation, and gluten-free diet, may have additional benefits, as do potential noninvasive and invasive procedures in recalcitrant cases. Medication selection should be tailored on an individual basis, considering side effects, comorbidities, and levels of peripheral and centralized pain. Nevertheless, there is an urgent need for long-term studies and RCTs assessing the efficacy of treatments for NCP.

Current trends in pain management after photorefractive and phototherapeutic keratectomy.

PURPOSE OF REVIEW: Since the introduction of photoablative procedures, postoperative pain management has been a major challenge for both the patient and the surgeon. Over the years, significant advances have been made in our ability to overcome this challenge. The purpose of this article is to discuss the most current strategies for pain control after photorefractive keratectomy and phototherapeutic keratectomy. RECENT FINDINGS: Methods for pain control can be targeted locally or systemically and can be pharmacological or nonpharmalogical. Options include anesthetics, NSAIDs, opiates, and anticonvulsants, as well as bandage contact lenses and corneal cooling. SUMMARY: Literature and experience provide insight on the efficacy and safety of the many options for post-photorefractive keratectomy pain control. Generally, refractive surgeons are using a combination approach to achieve pain control with excellent results.

The effect of silicone hydrogel bandage soft contact lens base curvature on comfort and outcomes after photorefractive keratectomy.

OBJECTIVE: To evaluate the relative pain and the relative amount of contact lens loss experienced using two different base curvatures (BCs) of the Acuvue Oasys bandage soft contact lens (BSCL) after photorefractive keratectomy (PRK). METHODS: One hundred forty patients undergoing PRK on either the Allegretto or the VISX laser at the Joint Warfighter Refractive Surgery Center in Lackland AFB, TX, were randomized to one of the two different BCs of the Acuvue Oasys BSCL: 8.4 or 8.8 mm. Patients were evaluated on postoperative days 1 and 4 during which they completed a survey rating absolute pain in each eye on a visual analog pain scale. Lens loss was recorded throughout the study. RESULTS: Patients treated on the Allegretto laser preferred the 8.4-mm BC lens, whereas comfort after treatment on the VISX depended on corneal shape. For VISX, patients with very flat corneas (steep K ≤42 preoperative or ≤38 postoperatively) preferred an 8.8-mm BC lens while patients with very steep corneas (steep K >45 preoperative or >42 postoperative) preferred an 8.4-mm BC lens, though these results were largely not statistically significant. Patients who lost their lenses prematurely tended to be those whose corneal curvature did not match their contact lens BC. CONCLUSIONS: Individuals treated with the Allegretto laser or individuals with more prolate corneas should likely be fit with an 8.4-mm BC Acuvue Oasys BSCL while individuals with more oblate corneas should likely be fit with an 8.8-mm BC lens to minimize postoperative pain and premature BSCL loss.

Scleral buckle removal in the vitrectomy era: a 20-year clinical experience.

PURPOSE: To describe the effect of scleral buckle (SB) removal on preoperative symptoms and signs prompting removal and to assess the risk of recurrent retinal detachment (RD) after SB removal. METHODS: A retrospective study of 36 patients who underwent SB removal between August 1988 and December 2007 was performed. Indications for SB removal, presence or absence of pain or diplopia, and recurrence of RD were recorded. Composite RD rates were estimated from previously published studies and stratified into those occurring during the previtrectomy era versus later (1980 to present). RESULTS: Mean follow-up time was 75.5 months after SB removal. Thirty-two of 33 patients (97%) who had preoperative pain had symptom relief. Twelve of 12 patients who had clinical infection had resolution. Of the four patients with diplopia, two experienced complete resolution and two reported substantial improvement but required prisms to obtain single vision. Four of 34 patients (12%) whose retinas were attached at the time of SB removal developed recurrent RD but were successfully repaired without significant visual loss from the RD. CONCLUSION: Scleral buckle removal is effective in eliminating SB-related pain and infection. Symptomatic diplopia can sometimes improve after SB removal. The rates of RD after SB removal observed in this study (12%) and in others performed in the era of vitrectomy were notably lower than those of previous reports.

Painful-blind eye: A forgotten palliative care.

Painful-blind eye (PBE) is a challenging and debilitating condition that greatly affects the quality of life of patients. Although PBE can result from a variety of etiologies, currently there is no guideline or consensus on how to approach therapeutically these patients, and most treatments are experience-based. We summarized the evidence from available studies to investigate the current state of PBE treatment strategies. This review revealed that the information available about therapeutic approaches in patients with PBE is insufficient and outdated, therefore, new experimental and larger studies are needed to reach an agreement about this condition.

Treatment Effect and Pain During Treatment With Intense Pulsed-Light Therapy According to the Light Guide in Patients With Meibomian Gland Dysfunction.

PURPOSE: We investigated whether there is a difference in the treatment effect and pain during the treatment of meibomian gland dysfunction (MGD) with intense pulsed-light (IPL) between new light guide and conventional light guide. METHODS: We retrospectively reviewed medical records of 85 patients (170 eyes) who underwent IPL treatment of the upper and lower eyelids 3 times, at 3-week intervals, for MGD. Patients treated with the 6-mm or 8 × 15-mm cylindrical light guide were designated as group A or group B, respectively. The ocular surface disease index (OSDI), dry eye (DE), and MGD parameters were obtained before the first and after the third IPL treatments. Visual analog scale (VAS) scores were obtained at every IPL treatment. OSDI, DE, and MGD parameters and VAS scores were compared between the groups. RESULTS: VAS scores at the first, second, and third IPL treatments were lower in group A than in group B. OSDI, DE, and MGD parameters were improved after 3 IPL treatments in both groups. There were no significant differences in OSDI, DE symptoms, and MGD parameters between before the first IPL treatment and after the third IPL treatment between the groups. CONCLUSIONS: Using the new 6-mm cylindrical light guide for IPL treatment in patients with MGD induced less pain during treatment and had similar treatment effects to the conventional 8 × 15-mm light guide. The new 6-mm cylindrical light guide can be useful when treating patients with dark or hyperpigmented skin and for pediatric patients with low compliance.

Effect of non-invasive intranasal neurostimulation on tear volume, dryness and ocular pain.

PURPOSE: To evaluate the effect of one TrueTear session on change in tear volume and symptoms of dryness and ocular pain. METHODS: Retrospective interventional case series of patients seen in a dry eye clinic. Seventy-five individuals underwent an ocular surface examination and one session of neurostimulation. Outcome measures included objective change in tear volume measured via phenol red test, and subjective change in sensations of dryness and ocular pain measured on a 0-10 Numerical Rating Scale. RESULTS: The mean age of the 75 individuals was 59±13 years, and the majority were male (73%). Intranasal neurostimulation increased tear volume (mean 13.40±8.00 mm, p<0.0005) and reduced intensities of dryness (mean -2.85±2.79, p<0.0005) and ocular pain (mean -1.48±2.41, p<0.0005 for both). However, these effects were independent of one another as change in symptom report did not correlate with change in tear volume (r=-0.13, p=0.25 for dryness; r=0.07, p=0.56 for pain). In a multivariable model, the strongest predictors for increased tear volume were lower baseline tear volume (standardised beta (ß)=-0.50, p<0.0005) and absence of an autoimmune disease (ß=-0.36, p=0.001) (R2=0.30). The strongest predictors for reduced dryness and pain scores were lower baseline dryness and ocular pain scores. No complications related to neurostimulation were noted. CONCLUSION: Intranasal neurostimulation increased tear volume and reduced intensities of dryness and ocular pain, independently of one another.

[Corneal perforation due to 'lost' contact lenses]. / Corneaperforatie door 'zoekgeraakte' contactlenzen.

An 87-year-old woman with Alzheimer's disease was referred to our eye clinic with a large corneal perforation of her right eye. On further examination a total of 15 contact lenses were found under the upper eyelid of her right eye; several lenses were also found in her left eye. During further evaluation we learned that our patient had experienced severe, recurrent and painful blepharoconjunctivitis for the past 3 years, for which she had consulted several ophthalmologists and other medical practitioners. The last time our patient had inserted a contact lens was more than 3 years previously. We therefore concluded that the retained contact lenses had caused an infectious ulcer which led to a corneal perforation. The patient underwent a perforating keratoplasty, which restored the eyesight in her right eye. Removal of the retained contact lenses gave our patient relief from her severe chronic eye pain.

Efficacy of autologous serum tears for treatment of neuropathic corneal pain.

OBJECTIVE: Corneal nerve damage may result in neuropathic corneal pain (NCP). Autologous serum tears (AST) have been shown to results in nerve regeneration and may help alleviate corneal pain. This study aimed to evaluate the efficacy of AST in the treatment of NCP. METHODS: This was a retrospective case-control study. Sixteen patients suffering from severe NCP and no current ocular surface disease were compared to 12 controls. In vivo confocal microscopy (IVCM) (HRT3/RCM; Heidelberg Engineering GmbH, Germany) of the central corneas was performed bilaterally. Change in pain severity (scale of 0-10), corneal nerve density, tortuosity, reflectivity and presence of beading and micro-neuromas before and after treatment were recorded. RESULTS: All patients had severe pain, with a mean of 9.1 ±â€¯0.2 (range 8-10). Subbasal nerves were significantly decreased before treatment as compared to controls, including total nerve length (10,935.5 ±â€¯1264.3 vs. 24,714.4 ±â€¯1056.2 µm/mm2; p < 0.0001) and total number of nerves (10.5 ±â€¯1.4 vs. 28.6 ±â€¯2.0; p < 0.0001), respectively. Morphologically, significantly increased reflectivity (2.9 ±â€¯0.2 vs. 1.2 ±â€¯0.1; p = 0.00008) and tortuosity (2.4 ±â€¯0.2 vs. 1.7 ±â€¯0.1; p = 0.001), both graded on a scale of 0-4, were noted. After a mean of 3.8 ±â€¯0.5 months (range 1-8 months) of AST treatment, pain severity decreased to 3.1 ±â€¯0.3 (range 0-4), (p < 0.0001). Further, IVCM demonstrated a significant improvement (p < 0.005) in total nerve length (17,351.3 ±â€¯1395.6  µm/mm2) and number (15.1 ±â€¯1.6), as well as significant decrease in reflectivity (2.4 ±â€¯0.2; p = 0.001) and tortuosity (2.2 ±â€¯0.2; p = 0.001). CONCLUSION: IVCM demonstrates underlying alterations of the subbasal corneal nerve plexus in patients suffering from debilitating NCP. AST-induced nerve regeneration is seen following treatment with AST, which correlates with improvement in patient symptoms of NCP.

[Evaluation of the quality of life of adult patients treated in low vision at the CHU-IOTA]. / Évaluation de la qualité de vie des patients adultes pris en charge en basse vision au CHU-IOTA.

INTRODUCTION: Visual impairment is a handicap defined as any alteration of visual function responsible for a partial or total limitation of the activities of daily living (OMS, 2004). The objective of this study is to assess quality of life in patients before and after management of low vision. PATIENTS AND METHODS: This was a mono-centric, transverse, analytical study over a period of 6 months. Our study population included all adult patients seen in ophthalmologic consultation and followed in the low vision unit with visual acuity less than 3/10 and greater than or equal to 1/20 in the best eye with best optical correction. The National Eye Institute's quality of life questionnaire, the NEF VFQ 25, was administered to patients on site prior to management and then a month later. RESULTS: Low-vision management improved overall the dimensions of the quality of life questionnaire. Following the end-of-care assessment, the score for ocular pain was lowest (38.20), followed by the overall vision score (44.95) and near vision difficulty score (45.33). DISCUSSION: Our sample population was distinguished by a cultural mix, with diversity of beliefs and lifestyles, and also by the relatively advanced age of the subjects constituting it. This can influence the individual's perception of him- or herself within his or her environment, modifying the patient's estimation of his or her condition and therefore his or her behavior. CONCLUSION: Low-vision rehabilitation can improve the quality of life of visually impaired patients, particularly for near vision, activities of daily living and psychological health.

Persistent socket pain postenucleation and post evisceration: a systematic review.

PURPOSE: To investigate causes, diagnostics and treatment modalities for persistent socket pain (PSP) after enucleation and evisceration. METHODS: A systematic search was undertaken in accordance with the PRISMA Statement, in PubMed, Embase.com and Thomson Reuters/Web of Science. We searched for relevant papers until the 28th of July 2016. Inclusion criteria were (1) patients with a history of enucleation or evisceration, (2) PSP, (3) report of the cause and/or used diagnostics and/or treatment modality, (4) full text in English, Dutch or Spanish language. Excluded were (1) review articles, (2) comments, and publications concerning, (3) nonhumans, (4) exenterated patients, (5) acute postoperative pain, or (6) periorbital pain without pain in the socket. Given the lack of high quality evidence from randomized controlled trials, we examined all available evidence from primary observational studies and assessed quality within this lower level of evidence. RESULTS: A total of 32 studies were included. Causes of PSP found were prosthesis-related (n = 5), dry socket (n = 2), trochleitis (n = 3), compression of the trigeminal nerve (n = 2), implant-related (n = unknown), inflammation (n = 5), surgery-related (n = 4), neuromas (n = 8), malignant tumours (n = 3), psychiatric/psychosocial (n = 2), phantom pain (n = 149), rarer entities (n = 3) or unknown (n = 14). Nonsurgical treatments suffice for conditions as trochleitis, prosthesis-related pain, dry socket and for phantom pain. Other causes of pain may require more invasive treatments such as implant removal. CONCLUSION: Careful history and examination can give some direction in the diagnostic procedure; however, PSP is probably multifactorial and the specific origin(s) may remain uncertain. Implant replacement can be an effective treatment. Studies to identifiy less invasive procedures are required.