Information
Editors
Pain in and around the Eye
Essentials
- 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.
Conditions requiring immediate treatment
Acute angle-closure glaucoma
- See Glaucoma.
- Symptoms
- Severe eye pain; may also be felt as severe pain in the head area.
- Nausea
- Blurring of vision
- Halo phenomena
- Findings
- Often severely reduced visual acuity
- Often mid-dilated pupil
- Eyeball hard on palpation
- Opaque cornea
- High intraocular pressure, as high as exceeding 60 mmHg
- Treatment and referral for specialized care
- 250-500 mg acetazolamide p.o. (must not be given to patients with sulfa allergy)
- Pilocarpine drops instilled into the eye
- Emergency referral to an ophthalmologist
Giant cell arteritis (temporal arteritis)
- See Giant Cell (Temporal) Arteritis.
- Symptoms and findings
- 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.
- Treatment
- Emergency referral to an ophthalmology unit
Conditions requiring urgent treatment
Keratitis
- See Keratitis.
- Symptoms and findings
- Eye pain possibly aggravated by closing the eye
- Foreign body sensation
- Photophobia
- Clear discharge
- Pericorneal redness
- Reduced visual acuity
- Inflammatory changes seen on fluorescein staining
- Treatment
- 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.
Iritis
- See Iridocyclitis (Iritis).
- Symptoms
- Eye pain often increased on exposure to light
- Pericorneal redness
- 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
Episcleritis
- See Episcleritis.
- Symptoms
- Pain and tenderness on palpation
- Sensitivity to draught (current of air)
- Treatment
- Analgesics, as necessary
- Moisturising drops
- 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.
Neck or shoulder muscle pain
- See also Tension Headache Neck and Shoulder Pain.
- Pain in the deep neck muscles radiates to the lateral side of the eye (Image 1).
- Tightness and pain in the superficial neck muscles and the anterior margin of the trapezius muscle radiate to the temporal region.
- Tightness and pain in the sternocleidomastoid muscle can be felt in the eyebrow region.
Other neurological causes
- Trigeminal neuralgia may occur in the area of the ophthalmic branch of the trigeminal nerve Trigeminal Neuralgia and other Facial Pain.
- Atypical facial pain may also occur in the eye area Trigeminal Neuralgia and other Facial Pain.
- Inconsistent with any other aetiology, the cause often remaining unclear.
- Neuropathic pain
- May be a sequel of a surgical procedure, such as supraorbital nerve damage caused by frontal sinus trephination.
- Neuralgia developing as a sequel of an ophthalmic herpes zoster infection
Causes originating from the sinuses
Occlusion problems
- Pain that radiates to the eye region may be due to malocclusion or referred from the masticatory muscles Malocclusion and Headache. 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.