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1 From the Instituto de Neurociencias, Universidad Miguel Hernández-Consejo Superior de Investigaciones Cientificas (CSIC), Campus de San Juan, San Juan de Alicante, Spain; and the 2 Cooperative Research Centre of Eye Research and Technology, University of New South Wales, Sydney, Australia.
| Abstract |
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METHODS. Six young subjects participated in the study. Using a gas esthesiometer, selective mechanical (air puffs at flows from 0 to 264 ml/min), chemical (080% CO2 in air), and thermal (air at temperatures from -10°C to +80°C) stimulation was performed on the center of the cornea and on the temporal conjunctiva. The intensity, degree of irritation, stinging and burning pain components, and thermal characteristics of the evoked sensation were evaluated after each stimulus in separate, 10-cm continuous visual analogue scales (VASs). The ability of the subjects to identify the quality of the stimulus applied to the cornea and the conjunctiva was also studied.
RESULTS. The subjective intensity and thermal components (cooling or warming) of the sensation reported after mechanical, chemical, and heat stimulation were similar in the conjunctiva and cornea, although lower VAS scores were always reported in the conjunctiva for the irritation and the stinging and burning pain components. In the cornea, stimulation with low temperatures was perceived as a cooling sensation with an irritative component. In the conjunctiva, cooling was perceived as a purely cold sensation. Subjects showed similar discrimination capability in the cornea and the conjunctiva for the various types of stimuli.
CONCLUSIONS. Sensations evoked in the cornea by selective mechanical, chemical, and heat and cold stimulation always presented an irritation component. In the conjunctiva, stimuli of the same intensity are always perceived as less irritating than in the cornea. Cold and other non-noxious subqualities of sensation can be evoked in the conjunctiva.
| Introduction |
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A more accurate procedure for stimulating the ocular surface was recently made available by the gas esthesiometer,7 an instrument that allows the delivery of gas pulses of controlled mechanical force, temperature, and varying CO2 concentration to the ocular surface. In humans, application with the gas esthesiometer of mechanical force, noxious heat, and low pH to the cornea evokes unpleasant sensations, with the degree of irritation, quality of pain, and thermal characteristics varying with the modality of stimulus. In contrast, moderate cold stimulation of the cornea elicits an innocuous sensation of cooling that becomes irritating when low temperatures are achieved.8 In the human conjunctiva, a similar study of the sensations evoked by selective application of different modalities of stimuli has not been performed. In the present work, the psychophysical characteristics of the sensations elicited by mechanical, thermal, and chemical stimulation of the bulbar conjunctiva with the gas esthesiometer were analyzed in human subjects and compared with those obtained from the cornea. Preliminary results have been published in abstract form.9
| Materials and Methods |
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Esthesiometry
A gas esthesiometer previously described7
was used
to apply to the corneal or conjunctival surface 3-sec gas jets of
adjustable flow, composition, and temperature, separated by 2-minute
pauses. Selective mechanical stimulation consisted of a series of nine
pulses of air at variable flow (0264 ml/min) heated to 50°C at the
tip of the probe to prevent changes in the temperature of the ocular
surface during the air puff. A series of nine pulses of air and
CO2 mixture of different concentrations (080%
CO2) at 50°C and with a flow 6.25 ml/min below
mechanical threshold was used for chemical stimulation. Thermal (heat
and cold) stimulation was performed by applying to the cornea and
conjunctiva 10 pulses of air at different temperatures (-10°C to
+80°C), which produced variations of the basal corneal temperature
(34.4°C) of -5°C to +3°C (see Refs. 7
and
8
) at a flow rate 6.25 ml/min below mechanical
threshold. In all experiments, pulses of different intensity were
applied randomly. Mechanical threshold was determined using the method
of levels.10
Sensation threshold for chemical and thermal
stimulation was determined with the method of minimum stimulus, that
is, the lowest intensity of stimulus that evoked a response of 0.5 VAS
units or more.8
The esthesiometer probe was located in a slit lamp table and its tip was placed at a distance of 5 mm from the ocular surface measured with a transparent ruler, perpendicular to the center of the cornea or the temporal conjunctiva (5 mm from the limbus). The subject was asked to blink immediately before the onset of each stimulus, which was identified by the click produced by the opening of a valve inside the probe. Immediately after each individual stimulus, the subject evaluated sequentially, in six separate, continuous, horizontal VASs, the components of the sensation experienced (intensity, irritation, stinging and burning components of the irritation, and warming or cooling thermal components). Intensityresponse curves for the various parameters of the sensation were subsequently made.7 8
The ability of the subjects to identify the type of stimulus applied to the cornea and the conjunctiva was also evaluated in a separate group of experiments. Mechanical, chemical, and hot and cold stimuli of the same subjective intensity (3 VAS units) were randomly applied twice to both eyes. The conjunctiva and the cornea were explored in separate sessions. Subjects were asked to identify the quality of the stimulus that had been delivered, based on the experience obtained in a previous stimulation series in which the different types of stimuli were identified and applied immediately afterward.
Data were expressed as mean ± SEM of the values from the six subjects (both eyes) in whom corneal and conjunctival responses were determined. Pearson product moment correlation was performed to measure the association between the intensity of the stimulus and the response of subjects (VAS values). If the correlation was significant (P < 0.05), the dependence of VAS scores on the intensity of the stimulus was predicted using linear regression. Slopes of linear regression lines were compared, to find differences between corneal and conjunctival responses.
| Results |
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Correlation between the Different Components of the
Sensations
In Figure 4
, the intensityresponse curves for the parameters intensity and
irritation were represented together, to examine for associations
between intensity detection and unpleasantness of the sensations evoked
by the different stimulus modalities.
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In contrast, in the case of the conjunctiva the curves of intensity and irritation obtained by mechanical stimulation did not overlap (Fig. 4A , right), suggesting that in this tissue, partially separated neural pathways are used to signal innocuous mechanical stimuli and pain (see the Discussion section), whereas for chemical and hot stimulation, intensityresponse curves for the parameters intensity and irritation overlapped, indicating a common neural pathway. Low-temperature stimuli produced a distinct sensation of cooling devoid of an irritative component (Figs. 4B 4C , right).
Identification of the Type of Stimulus
Table 2
presents the percentage of correct identifications of the type of
stimulus applied to the cornea and the conjunctiva. The ability of
subjects to identify the quality of stimuli with the same subjective
intensity was high and similar in both structures. Chemical and hot
stimuli were slightly less accurately identified in the conjunctiva
than in the cornea.
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| Discussion |
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Previous reports on conjunctival and corneal sensitivity were largely
limited to the determination of mechanical thresholds and included only
incidental comments about the quality of the evoked
sensation.2
3
4
5
13
14
15
16
17
With the Cochet-Bonnet
esthesiometer, mechanical threshold values were markedly lower in the
cornea than in the conjunctiva, in which large regional variations in
sensitivity have been additionally reported.14
15
Differences in mechanical threshold between cornea and conjunctiva were
less pronounced when a pneumatic esthesiometer using air at room
temperature was used.17
In the present experiments, in
which mechanical threshold was determined with a jet of warmed gas that
prevented cooling of the ocular surface, no differences in threshold
were found between tissues. The discrepancy in mechanical thresholds
obtained with the different instruments possibly reflect a variable
recruitment of the various types of corneal and conjunctival sensory
afferents. Although all procedures are expected to stimulate thin
myelinated and unmyelinated polymodal sensory fibers, touching the
cornea with the Cochet-Bonnet esthesiometer fully activates A
mechanosensory fibers,18
which are important for the
production of a sensation of sharp pain and this population, seems to
be poorly recruited by mechanical stimulation with a gas
jet.8
Moreover, the higher innervation density of the
cornea in comparison with the conjunctiva may be important in detecting
a punctate stimulus performed with a hair, but may be less critical
when a larger surface is stimulated, as occurs with a gas jet. Finally,
a variable recruitment of cold-sensitive fibers in the cornea and the
conjunctiva by the gas esthesiometers may be the reason for the small
differences in detection thresholds obtained with these
instruments.8
17
In the cornea, the intensity and irritation curves of the sensation evoked by mechanical stimulation overlapped, whereas in the conjunctiva, mechanical stimuli of low and moderate magnitude had a very low irritation component, although their intensities were clearly detected. These observations suggest that the conjunctiva, unlike the cornea, contains low-threshold mechanoreceptor afferent nerves19 that are initially activated by stimuli of weak intensity that evoke innocuous sensations, in addition to the presence of nociceptor fibers, whose recruitment by higher intensity stimuli produce irritation and pain.20 They further confirm that in the cornea mechanical stimuli are encoded exclusively by sensory afferent nerves of the nociceptor type.8
Differences in the subjective intensity and irritation response curves were not apparent when stimulation was performed with CO2, a stimulus that recruits mainly polymodal sensory fibers,6 evoking intensity and irritation response curves that overlapped completely, both for the cornea and the conjunctiva. VAS scores were comparatively lower in the case of the conjunctiva, possibly because the decrease in pH caused by CO2 is more effectively buffered in the richly vascularized conjunctival tissue than in the cornea.
Low-temperature stimuli of moderate intensity provoked purely cold sensations in the conjunctiva and the cornea. In the cornea, more pronounced temperature declines also elicited irritation and pain.3 8 These unpleasant sensations were not evoked by comparable stimuli in the conjunctiva, in which lower VAS scores than in the cornea were also reported in response to similar cold stimuli. This suggests that in the conjunctiva, as seems to occur in the cornea, moderate temperature changes caused by the cooled air jet activates exclusively thermal receptor endings sensitive to cold,21 which evokes innocuous thermal sensations.3 Presumably, in the conjunctiva temperature reductions caused by cold air are less pronounced than in the cornea, because of the attenuation of temperature changes by the blood flow. Accordingly, a local temperature decrease may be insufficient to activate conjunctival polymodal nociceptors, as in the cornea, when extreme cold is applied.8 Moreover, the lower density of polymodal nociceptive fibers in the conjunctiva reduces the probability of recruitment of nociceptive endings by intense cooling.
Positive identification of the modality of the applied stimulus was made for the cornea and the conjunctiva. This is in agreement with the observations made by Kenshalo3 of pure thermal sensations arising from the conjunctiva and confirms those of Acosta et al.8 in the cornea, where the presence of thermal sensations has been a matter of discussion for years.2 3 4 5 8 Furthermore the present results support the interpretation that the final subquality of sensations arising from the ocular surface is determined by simultaneous activation of different populations of sensory afferents. When polymodal nociceptive fibers are activated, subjects experience a blended sensation that possesses an identifiable quality but is dominated by an irritation component.
| Acknowledgements |
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| Footnotes |
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Submitted for publication February 5, 2001; revised April 16, 2001; accepted April 26, 2001.
Commercial relationships policy: N.
The publication costs of this article were defrayed in part by page charge payment. This article must therefore be marked "advertisement" in accordance with 18 U.S.C.
1734 solely to indicate this fact.
Corresponding author: Juana Gallar, Instituto de Neurociencias, Universidad Miguel Hernández-CSIC, Campus de San Juan, Aptdo. 18, 03550 San Juan de Alicante, Spain. juana.gallar{at}umh.es
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