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Eye Pain

By

Christopher J. Brady

, MD, Wilmer Eye Institute, Retina Division, Johns Hopkins University School of Medicine

Last full review/revision May 2021| Content last modified May 2021
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Eye pain may be described as sharp, aching, or throbbing and should be distinguished from superficial irritation or a foreign body sensation. In some disorders, pain is worsened by bright light. Eye pain may be caused by a serious disorder and requires prompt evaluation. Many causes of eye pain also cause a red eye.

Pathophysiology of Eye Pain

The cornea is richly innervated and highly sensitive to pain. Many disorders that affect the cornea or anterior chamber (eg, uveitis Overview of Uveitis Uveitis is defined as inflammation of the uveal tract—the iris, ciliary body, and choroid. However, the retina and fluid within the anterior chamber and vitreous are often involved as well.... read more Overview of Uveitis ) also cause pain via ciliary muscle spasm; when such spasm is present, bright light causes muscle contraction, worsening pain.

Etiology of Eye Pain

Evaluation of Eye Pain

History

History of present illness should address the onset, quality, and severity of pain and any history of prior episodes (eg, daily episodes in clusters). Important associated symptoms include true photophobia (shining a light into the unaffected eye causes pain in the affected eye when the affected eye is shut), decreased visual acuity, foreign body sensation and pain when blinking, and pain when moving the eye.

Past medical history should include known disorders that are risk factors for eye pain, including autoimmune disorders, multiple sclerosis, migraine, and sinus infections. Additional risk factors to assess include use (and overuse) of contact lenses (contact lens keratitis), exposure to excessive sunlight or to welding (ultraviolet keratitis Ultraviolet keratitis Superficial punctate keratitis is corneal inflammation of diverse causes characterized by scattered, fine, punctate corneal epithelial loss or damage. Symptoms are redness, lacrimation, photophobia... read more ), hammering or drilling metal (foreign body), and recent eye injury or surgery (endophthalmitis Endophthalmitis Endophthalmitis is an acute panuveitis resulting most often from bacterial infection. Most cases of endophthalmitis are caused by gram-positive bacteria, such as Staphylococcus epidermidis or... read more Endophthalmitis ).

Physical examination

Vital signs are checked for the presence of fever. The nose is inspected for purulent rhinorrhea, and the face is palpated for tenderness. If the eye is red, the preauricular region is checked for adenopathy. Hygiene during examination must be scrupulous when examining patients who have chemosis, preauricular adenopathy, punctate corneal staining, or a combination; these findings suggest epidemic keratoconjunctivitis Symptoms and Signs Viral conjunctivitis is a highly contagious acute conjunctival infection usually caused by an adenovirus. Symptoms include irritation, photophobia, and watery discharge. Diagnosis is clinical... read more Symptoms and Signs , which is highly contagious.

Eye examination should be as complete as possible for patients with eye pain. Best corrected visual acuity is checked. Visual fields are typically tested by confrontation in patients with eye pain, but this test can be insensitive (particularly for small defects) and unreliable because of poor patient cooperation. A light is moved from one eye to the other to check for pupillary size and direct and consensual pupillary light responses. In patients who have unilateral eye pain, a light is shined in the unaffected eye while the affected eye is shut; pain in the affected eye represents true photophobia. Extraocular movements are checked. The orbital and periorbital structures are inspected. Conjunctival injection that seems most intense and confluent around the cornea and limbus is called ciliary flush.

Slit-lamp examination is done if possible. The cornea is stained with fluorescein and examined under magnification with cobalt blue light. If a slit lamp is unavailable, the cornea can be examined after fluorescein staining with a Wood light using magnification. Ophthalmoscopy is done, and ocular pressures are measured (tonometry). In patients with a foreign body sensation or unexplained corneal abrasions, the eyelids are everted and examined for foreign bodies.

Red flags

The following findings are of particular concern:

  • Vomiting, halos around lights, or corneal edema

  • Signs of systemic infection (eg, fever, chills)

  • Decreased visual acuity

  • Proptosis

  • Impaired extraocular motility

Interpretation of findings

Scratchiness or a foreign body sensation is most often caused by disorders of the eyelids, conjunctivae, or superficial cornea. Photosensitivity is possible.

Deeper pain—often described as aching or throbbing—usually indicates a serious disorder such as glaucoma Overview of Glaucoma Glaucomas are a group of eye disorders characterized by progressive optic nerve damage in which an important part is a relative increase in intraocular pressure (IOP) that can lead to irreversible... read more , uveitis Overview of Uveitis Uveitis is defined as inflammation of the uveal tract—the iris, ciliary body, and choroid. However, the retina and fluid within the anterior chamber and vitreous are often involved as well.... read more Overview of Uveitis , scleritis Scleritis Scleritis is a severe, destructive, vision-threatening inflammation involving the deep episclera and sclera. Symptoms are moderate to marked pain, hyperemia of the globe, lacrimation, and photophobia... read more Scleritis , endophthalmitis Endophthalmitis Endophthalmitis is an acute panuveitis resulting most often from bacterial infection. Most cases of endophthalmitis are caused by gram-positive bacteria, such as Staphylococcus epidermidis or... read more Endophthalmitis , orbital cellulitis Preseptal and Orbital Cellulitis Preseptal cellulitis (periorbital cellulitis) is infection of the eyelid and surrounding skin anterior to the orbital septum. Orbital cellulitis is infection of the orbital tissues posterior... read more Preseptal and Orbital Cellulitis , or orbital pseudotumor. Within this group, eyelid swelling, proptosis, or both and impaired extraocular movements or visual acuity suggest orbital pseudotumor, orbital cellulitis, or possibly severe endophthalmitis. Fever, chills, and tenderness suggest infection (eg, orbital cellulitis, sinusitis Sinusitis Sinusitis is inflammation of the paranasal sinuses due to viral, bacterial, or fungal infections or allergic reactions. Symptoms include nasal obstruction and congestion, purulent rhinorrhea... read more Sinusitis , sepsis).

A red eye suggests that the disorder causing pain is ocular rather than referred.

If pain develops in the affected eye in response to shining light in the unaffected eye when the affected eye is shut (true photophobia), the cause is most often a corneal lesion or uveitis.

Ciliary flush suggests that inflammation is within the eye (eg, due to uveitis or glaucoma) and not the conjunctiva.

If topical anesthetic drops (eg, proparacaine) abolish pain in a red eye, the cause is probably a corneal disorder.

Some findings are more suggestive of particular disorders. Pain and photophobia days after blunt eye trauma suggest posttraumatic uveitis. Hammering or drilling metal is a risk factor for occult metal intraocular foreign body. Pain with movement of extraocular muscles and loss of pupillary light response that is disproportionate to loss of visual acuity suggest optic neuritis.

Testing

Testing is not usually necessary, with some exceptions (see table Some Causes of Eye Pain Some Causes of Eye Pain Eye pain may be described as sharp, aching, or throbbing and should be distinguished from superficial irritation or a foreign body sensation. In some disorders, pain is worsened by bright light... read more ). Gonioscopy is done if glaucoma Overview of Glaucoma Glaucomas are a group of eye disorders characterized by progressive optic nerve damage in which an important part is a relative increase in intraocular pressure (IOP) that can lead to irreversible... read more is suspected based on increased intraocular pressure. Imaging, usually with CT or MRI, is done if orbital pseudotumor or orbital cellulitis Preseptal and Orbital Cellulitis Preseptal cellulitis (periorbital cellulitis) is infection of the eyelid and surrounding skin anterior to the orbital septum. Orbital cellulitis is infection of the orbital tissues posterior... read more Preseptal and Orbital Cellulitis is suspected, or if sinusitis Sinusitis Sinusitis is inflammation of the paranasal sinuses due to viral, bacterial, or fungal infections or allergic reactions. Symptoms include nasal obstruction and congestion, purulent rhinorrhea... read more Sinusitis is suspected but the diagnosis is not clinically clear. MRI is often done when optic neuritis is suspected, looking for demyelinating lesions in the brain suggesting multiple sclerosis Multiple Sclerosis (MS) Multiple sclerosis (MS) is characterized by disseminated patches of demyelination in the brain and spinal cord. Common symptoms include visual and oculomotor abnormalities, paresthesias, weakness... read more Multiple Sclerosis (MS) .

Treatment of Eye Pain

The cause of pain is treated. Pain itself is also treated. Systemic analgesics are used as needed. Pain caused by uveitis Overview of Uveitis Uveitis is defined as inflammation of the uveal tract—the iris, ciliary body, and choroid. However, the retina and fluid within the anterior chamber and vitreous are often involved as well.... read more Overview of Uveitis and many corneal lesions is also relieved with cycloplegic eye drops (eg, cyclopentolate 1% four times a day).

Key Points

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