Pain or aching can radiate to the eye region from many structures in the face, head and neck.
Diagnosis can often be based on the history alone, i.e. the nature and localization of the pain. Careful history taking forms the cornerstone of identifying the cause of pain.
Causes of acute eye pain requiring immediate treatment should be recognized.
Pain often primarily in the temporal area, the scalp and the jaw
Impaired general condition
Reduced visual acuity
Elevated CRP and ESR
Referral for specialized care
Suspicion of giant cell arteritis requires emergency referral to an internist.
If the differential diagnosis is unclear and impairment of visual acuity is significant, the patient can also be referred to an emergency ophthalmology unit.
Endophthalmitis
Predisposing factors
Surgery of the eye area or intraocular injection within the last 2-5 days
Immunosuppressive medication
Severe systemic disease
Symptoms and findings
Pain in the eye area, headache
Photophobia
Significant reduction of visual acuity
Inflammatory cells in the anterior chamber (hypopyon)
Red eye
Possibly chemosis (fluid underneath the conjunctiva)
Opaque cornea
Accumulation of inflammatory cells in the anterior chamber and the vitreous space, best seen under a biomicroscope. In patients with endophthalmitis, very high accumulation of inflammatory cells in the anterior chamber can sometimes even be seen with the naked eye or using loupes.
Keratitis should be treated by an ophthalmologist. Do not hesitate to consult an ophthalmologist by phone. Mild keratitis responding to treatment will not necessarily require emergency referral but rapidly progressing conditions such as aggressive acanthamoeba infection require emergency treatment.
Visual acuity often normal at first but may be severely reduced as the inflammation progresses
Pupil in the inflamed eye often smaller
Treatment
Referral to an ophthalmologist within a few days. Iritis with severe symptoms may require emergency treatment.
Primary treatment of recurrent iritis or iritis with milder symptoms can often be done by a GP (an ophthalmologist should preferably be consulted by phone on how to start the treatment). If a GP starts the treatment, further investigation by an ophthalmologist will be needed within a few days.
Scleritis
This is a rare condition but if the healing of episcleritis is delayed, the patient should be referred to an ophthalmologist to exclude scleritis.
Symptoms
From local tenderness to severe pain
There may be photophobia.
Visual acuity may be reduced.
Local erythema of scleral blood vessels (when the conjunctiva is moved, the deepest vessels do not move)
Treatment
Refer to an ophthalmologist if the healing of episcleritis is prolonged and the suspicion of scleritis arises.
Consult an on-call ophthalmologist by phone, as necessary.
Conditions requiring monitoring and referral, as necessary
Referral to an ophthalmologist if the condition continues for more than 3-4 weeks
If scleritis is suspected in a patient with severe symptoms, consider emergency referral.
Other than ocular causes
Primary headaches
Migraine headache often radiates to behind or to the side of the eye. A migraine attack can also start in the eye region or behind the eye. See also Migraine.
Tension headache is associated with muscle tension or pain in the neck area. It is located mainly at the temples and often uni- or bilaterally in the eye region, frequently as a band-like sensation. See Tension Headache.
Cluster headache, or Horton's neuralgia Cluster Headache (Horton's Syndrome), causes extremely severe, often drilling, unilateral pain in the eye area. As the name suggests, the pain occurs in recurring attacks, or clusters.
Inverted papilloma and sinus tumours may occur as rarer causes.
Occlusion problems
Pain that radiates to the eye region may be due to malocclusion or referred from the masticatory muscles Bruxism. Occlusion problems may occur in adults, as well.
If a long time has passed since occlusion was last checked, a dental examination should be recommended.