Eye Pain

Aka: Eye Pain

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II. History

  1. Eye Foreign Body Sensation
    1. Corneal involvement (e.g. Corneal Abrasion, sicca syndrome)
  2. Eye scratchy or gritty Sensation
    1. Conjunctivitis
  3. Contact Lens Wear
    1. Risk of Infectious Keratitis
  4. Photophobia (when combined with Eye Pain, associated with Vision threatening conditions)
    1. Corneal involvement (e.g. Keratitis, Corneal Abrasion)
    2. Uveitis
    3. Scleritis
    4. Migraine Headache
    5. Acute Angle-Closure Glaucoma (Narrow Angle Glaucoma)
  5. Eye Discharge
    1. Mucopurulent discharge
      1. Bacterial Conjunctivitis (including Gonococcal Conjunctivitis)
    2. Watery discharge
      1. Viral Conjunctivitis
      2. Corneal Abrasion
      3. Allergic Conjunctivitis
  6. Headache
    1. Acute Angle-Closure Glaucoma (Narrow Angle Glaucoma)
    2. Scleritis (esp. Rheumatologic Conditions)
    3. Migraine Headache
    4. Cluster Headache
    5. Optic Neuritis (esp. Multiple Sclerosis, also causes Vision Loss)
    6. Orbital Cellulitis
    7. Temporal Arteritis (temporal Headache, Jaw Claudication)
  7. Vision Loss with Eye Pain (emergent ophthalmology evaluation needed)
    1. Acute Angle-Closure Glaucoma (Narrow Angle Glaucoma)
    2. HSV Keratitis
    3. Optic Neuritis
    4. Orbital Cellulitis
  8. Eye Pain worse with eye movement
    1. Optic Neuritis
    2. Scleritis
    3. Corneal Foreign Body
  9. Autoimmune Conditions (Rheumatologic Disease)
    1. Scleritis
    2. Uveitis
    3. Optic Neuritis
  10. Chemical Eye Exposure
    1. See Chemical Eye Injury
  11. Eye Trauma
    1. See Eye Injury
    2. See Corneal Foreign Body
    3. See Blunt Eye Trauma
  12. Other contributing conditions
    1. Dry Eye Syndrome

III. Exam

  1. See Eye Exam
  2. Increased Intraocular Pressure (esp. >40-50 mmHg)
    1. See Increased Intraocular Pressure
    2. Acute Angle-Closure Glaucoma (Narrow Angle Glaucoma)
  3. Extraocular Movement pain
    1. See Extraocular Movement
    2. Optic Neuritis
    3. Orbital Cellulitis
    4. Scleritis
    5. Acute Angle-Closure Glaucoma (Narrow Angle Glaucoma)
  4. Decreased Visual Fields
    1. See Visual Field Deficit
    2. Optic Neuritis
  5. Decreased Visual Acuity
    1. See Acute Vision Loss
    2. Optic Neuritis
    3. Narrow Angle Glaucoma
    4. Globe Rupture
    5. Uveitis
    6. Temporal Arteritis
  6. Eyelid Swelling
    1. See Eyelid Swelling
    2. See Red Eyelid
    3. Hordeolum
    4. Orbital Cellulitis (or Preseptal Cellulitis)
  7. Eyelid Vesicles
    1. Herpes Simplex Keratitis
    2. Herpes Zoster Ophthalmicus
  8. Photophobia on penlight test (light applied from 6 inches for 2 seconds)
    1. Uveitis
    2. Keratitis
    3. Scleritis
    4. Migraine Headache
  9. Fluorescein uptake
    1. Corneal Abrasion
    2. Corneal Ulcer
    3. Uveitis
    4. Keratitis
    5. Globe Rupture (Seidel Sign)
  10. Pupil defects
    1. See Pupil Disorder
    2. Optic Neuritis
      1. Afferent pupil defect (Swinging Flashlight Test)
    3. Anterior Uveitis
      1. Aniscoria (Unequal Pupils)
    4. Acute Angle-Closure Glaucoma (Narrow Angle Glaucoma)
      1. Fixed, dilated pupil

IV. Causes: Eye Pain with Visible lesions

  1. See Red Eye
  2. Ocular Foreign Body
  3. Entropion Conjunctivitis
  4. Hordeolum
  5. Chalazion
  6. Corneal Ulcer
  7. Interstitial Keratitis
  8. Iritis
  9. Iridocyclitis
  10. Glaucoma
  11. Ocular Herpetic infection
  12. Conjunctiva calcification
  13. Band keratopathy

V. Causes: Eye Pain without lesions (quiet non-Red Eye)

  1. See Eye Pain without Redness
  2. Visual Loss or Visual Field Deficit
    1. Narrow Angle Glaucoma
    2. Intraocular tumor
    3. Uveitis
    4. Posterior Scleritis
    5. Optic Neuropathy, Optic Neuritis or retrobulbar neuritis
  3. Associated neurologic deficits
    1. Tolosa-Hunt Syndrome
    2. Cavernous Sinus Thrombosis
    3. Transient Ischemic Attack or Cerebrovascular Accident
    4. Cluster Headache
    5. Trigeminal Neuralgia
  4. Associated Headache
    1. Migraine Headache
    2. Temporal Arteritis
    3. Acute Sinusitis (Ethmoid, Sphenoid, or Frontal Sinus involvement)
    4. Cluster Headache
    5. Increased Intracranial Pressure
  5. Consider other diagnoses
    1. Corneal Abrasion
    2. Graves Disease
    3. Eye strain

VI. Management: Urgent and Emergent Ophthalmology Consultation Indications

  1. Acute Vision Loss
  2. Severe photophobia
  3. Corneal Ulcer
  4. Hyphema
  5. Globe Rupture
  6. Ciliary Flush
  7. Proptosis
  8. Painful Red Eye with Miosis (Pupil Constriction) and Anisocoria >1 mm
  9. Keratitis
  10. Uveitis
  11. Acute angle closure Glaucoma
  12. Orbital or Periorbital Cellulitis
  13. Endophthalmalitis

VII. References

  1. Fiore (2011) Am Fam Physician 82(1): 69-73 [PubMed]
  2. Dargin (2008) Med Clin North Am 26(1): 119-216 [PubMed]
  3. Lee (2004) Neurol Clin 22(1): 75-97 [PubMed]
  4. Pflipsen (2016) Am Fam Physician 93(12): 991-8 [PubMed]
  5. Yedlinsky (2026) Am Fam Physician 114(1): 65-71 [PubMed]

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