Can Raynaud’s phenomenon cause the sensation of cold in the eyes, or is it merely a duplicate of other ocular causes such as dry‑eye disease or neuropathic corneal pain?

Raynaud's Phenomenon Does Not Directly Cause Cold Sensations in the Eyes

The sensation of "cold eyes" is not a recognized manifestation of Raynaud's phenomenon itself, but rather represents either neuropathic ocular pain, dry eye disease, or reflects systemic vascular changes that may affect retinal circulation in severe cases.

Understanding the Distinction

Raynaud's phenomenon is characterized by episodic digital arteriolar vasospasm triggered by cold or stress 1. While it primarily affects fingers and toes, research has demonstrated that severe Raynaud's can cause retinal capillary flow reduction (30% decrease during cold exposure, persisting 17% reduced for at least 10 minutes after) 2. However, this represents retinal vascular changes, not ocular surface symptoms.

The Real Culprits Behind "Cold Eye" Sensations

Neuropathic Ocular Pain (Primary Consideration)

When patients describe cold, burning, or unusual sensations in the eyes with minimal objective findings, suspect neuropathic ocular pain 3. This condition involves:

• Peripheral nerve dysfunction: Trigeminal nerve (V1) hyperexcitability causing spontaneous pain described as burning, stinging, aching, or abnormal temperature sensations 3
• Central sensitization: Pain disconnected from observable surface pathology 4
• Key diagnostic feature: Symptoms grossly outweigh clinical signs 3

Diagnostic approach:

1. Perform thorough ocular surface examination looking for aqueous tear deficiency, inflammation, epithelial erosions 3
2. Administer proparacaine challenge test: If pain improves with topical anesthetic, suggests peripheral/nociceptive component; if unchanged, indicates central neuropathic pain 4
3. Use validated questionnaires (NPSI-Eye or OPAS) to assess neuropathic pain qualities 3
4. Consider in vivo confocal microscopy to document nerve damage 4

Dry Eye Disease with Neurosensory Dysfunction

The 2024 Dry Eye Preferred Practice Pattern explicitly recognizes that dry eye includes neurosensory abnormalities 3, 5. Cold sensations may reflect:

• Abnormal cold thermoreceptor activity from inflammation and nerve damage 6
• Dysesthesias from altered corneal nerve function 6, 7
• Symptoms persisting despite treatment of tear film abnormalities 3

Clinical Algorithm

Step 1: Examine for objective dry eye signs

• Schirmer test, tear breakup time, corneal/conjunctival staining 3, 5
• Meibomian gland assessment 3

Step 2: Assess symptom-sign discordance

• If symptoms >> signs: strongly consider neuropathic component 3
• If symptoms persist after appropriate dry eye treatment: neuropathic pain likely 3

Step 3: Proparacaine challenge

• Complete relief → treat as nociceptive/peripheral pain
• Partial relief → mixed peripheral and central components (most common) 4
• No relief → central neuropathic pain 4

Step 4: Screen for systemic associations

• In patients with Raynaud's and connective tissue disease: evaluate for Sjögren syndrome using European-American Consensus criteria (Schirmer <5mm, ocular staining, anti-Ro/SSA antibodies) 3
• Sjögren patients may exhibit either neurotrophic (diminished symptoms despite signs) or neuropathic (heightened symptoms) phenotypes 8

Treatment Approach

For peripheral neuropathic pain:

• Topical nerve regenerative therapies (autologous serum tears) 3, 4
• Anti-inflammatory therapy: topical loteprednol first-line, then cyclosporine or lifitegrast 4
• Cryopreserved amniotic membrane for severe cases 4

For central neuropathic pain:

• Oral neuromodulators: pregabalin, gabapentin, duloxetine, amitriptyline, nortriptyline, or low-dose naltrexone 3
• Critical caveat: Requires 3-4 months at therapeutic dose to see effect—set expectations early 3
• Consider multidisciplinary approach with pain specialists and mental health professionals 3

Common Pitfalls

1. Dismissing symptoms as "just dry eye" when signs are minimal—this misses neuropathic pain diagnosis 3, 9
2. Attributing ocular symptoms directly to Raynaud's—while severe Raynaud's affects retinal circulation 2, ocular surface symptoms require separate evaluation
3. Expecting immediate response to neuromodulators—patients need counseling about 3-4 month timeline 3
4. Using preserved drops in hyperalgesic patients—switch to preservative-free formulations 4

The sensation of cold eyes represents ocular neuropathic pain or dry eye neurosensory dysfunction rather than a direct manifestation of Raynaud's phenomenon, though patients with severe Raynaud's and connective tissue disease warrant evaluation for Sjögren syndrome and its associated ocular complications 3, 2, 8.