Some Causes of Eye Pain
Cause | Suggestive Findings | Diagnostic Approach* |
|---|---|---|
Disorders affecting primarily the cornea† | ||
Contact lens keratitis | Ocular ache, grittiness, prolonged wearing of contact lenses, bilateral red eyes, lacrimation, corneal edema | History and physical examination, including ophthalmic examination if vision loss present |
Usually clear history of injury or high-risk activity such as grinding metal, unilateral pain when blinking, foreign body sensation Sometimes a predisposing disorder such as trichiasis (eyelashes touching the cornea) Lesion or foreign body visible on slit-lamp examination | History and physical examination, including ophthalmic examination, including eyelid eversion | |
Aching, foreign body sensation, photophobia, red eye, grayish opacity on cornea, followed by a visible crater Possibly history of sleeping with contact lenses | Scrapings for culture (done by ophthalmologist) | |
Epidemic keratoconjunctivitis (adenoviral conjunctivitis with keratitis) when severe | Ocular ache, grittiness, bilateral red eyes, copious watery discharge, preauricular lymphadenopathy, chemosis (bulging of the conjunctiva), often eyelid edema | History and physical examination, including ophthalmic examination if vision loss present |
Early: Unilateral vesicles and crusts on an erythematous base in a V1 distribution, sometimes affecting the tip of the nose Eyelid edema, red eye Late: Redness, quite severe pain Often associated with uveitis | Ophthalmic evaluation Viral culture if diagnosis is unclear | |
Acute: Onset after conjunctivitis, blisters on eyelid Late acute or recurrent: Classic dendritic corneal lesion on slit-lamp examination Usually unilateral (may be bilateral in children or patients with atopy) | History and physical examination, including ophthalmic examination Viral culture if diagnosis is unclear | |
Welder’s or UV keratitis | Onset hours after exposure to excessive UV light (eg, from welding or bright sun on snow) Bilateral; ocular ache, grittiness | History and physical examination, including ophthalmic examination if diagnosis is unclear |
Other ocular disorders | ||
Severe ocular ache, headache, nausea, vomiting, halos around lights, hazy cornea (caused by edema), marked erythema Intraocular pressure usually > 40 mm Hg | Gonioscopy by ophthalmologist | |
Ocular ache, ciliary flush, photophobia, often a risk factor (eg, autoimmune disorder, posttrauma) Cells and flare on slit-lamp examination Rarely hypopyon | Ophthalmic evaluation | |
Ocular ache, intense conjunctival hyperemia, photophobia, severely decreased visual acuity, risk factors (recent intraocular surgery, trauma, or bacteremia) Unilateral Cells and flare and commonly hypopyon on slit-lamp examination | Immediate ophthalmic evaluation and microbiologic testing (eg, Gram stain and culture of aspirates for endogenous endophthalmitis, blood and urine cultures) | |
Mild pain, which may worsen with eye movement Vision loss, ranging from a small scotoma to blindness Afferent pupillary defect (a particularly characteristic finding if some visual acuity is preserved) Eyelids and cornea normal, sometimes a swollen optic disk | Consideration of gadolinium-enhanced MRI of brain and orbits to look for optic nerve edema and demyelinating lesions within the brain (most commonly due to multiple sclerosis) | |
Ocular ache, periocular ache, red and swollen eyelids, proptosis, impaired extraocular movements, decreased visual acuity, fever Unilateral Sometimes preceded by symptoms of sinusitis | CT or MRI of orbits | |
Ocular ache, periocular ache (may be very severe), unilateral proptosis Impaired extraocular movements, periorbital edema, gradual onset | CT or MRI of orbits Biopsy | |
Pain very severe (often described as boring), photophobia, lacrimation, red or violaceous patches under bulbar conjunctiva, scleral edema Often history of autoimmune disorder | Ophthalmic evaluation | |
Disorders causing referred pain | ||
Prior episodes, characteristic temporal pattern (eg, clusters of episodes at the same time each day) Knifelike quality, rhinorrhea, lacrimation, facial flushing | History and physical examination | |
Prior episodes, aura, pulsatile pain, nausea, sometimes photosensitivity or photophobia | History and physical examination, including ophthalmic examination and sometimes MRI or CT of brain (eg, if onset after age 40 or if atypical neurological findings) | |
Sometimes periorbital edema but eye examination otherwise unremarkable Purulent rhinorrhea, headache, or eye or facial pain that varies with head position Facial tenderness, fever, sometimes productive nocturnal cough, halitosis | Sometimes CT | |
† Most patients have lacrimation and true photophobia (shining a light into the unaffected eye causes pain in the affected eye when the affected eye is shut). | ||
UV = ultraviolet; V1= ophthalmic division of the trigeminal nerve. | ||