Definition
A.Sensation of pain may affect the eyelid, conjunctiva, or cornea.
Incidence
A.Unknown. Pain in the eye is most often produced by conditions that do not threaten vision.
Pathogenesis
A.The external ocular surfaces and the uveal tract are richly innervated with pain receptors. As a result, lesions or disease processes affecting these surfaces can be acutely painful.
B.Pathology confined to the vitreous, retina, or optic nerve is rarely a source of pain.
Predisposing Factors
A.Eyelids: Inflammation such as hordeolum (stye), trichiasis (in-turned lash), and tarsal foreign bodies.
B.Conjunctiva: Viral and bacterial conjunctivitis or allergic conjunctivitis; toxic, chemical, and mechanical injuries.
C.Cornea: Keratitis (inflammation of the cornea) accompanying trauma, infection, exposure, vascular disease, or decreased lacrimation; microbial keratitis from contact use. If blood vessels invade the normally avascular corneal stroma, vision may become cloudy. Severe pain is a prominent symptom; movement of the lid typically exacerbates symptoms.
Common Complaints
A.Eye pain (sharp, dull, deep): The quality of the pain needs to be considered. Deep pain is suggestive of an intraocular problem. Inflammation and rapidly expanding mass lesions may cause deep pain. Displacement of the globe and diplopia may ensue.
B.Eye movement may cause sharp pain due to meningeal inflammation (the extraocular rectus muscles insert along the dura of the nerve sheath at the orbital apex). Most cases are idiopathic, but 10% to 15% are associated with multiple sclerosis.
Other Signs and Symptoms
These symptoms may be unilateral or bilateral.
A.Eyelids:
1.Tenderness.
2.Sensation of foreign body.
3.Redness.
4.Edema.
B.Conjunctiva:
1.Mild burning.
2.Sensation of foreign body.
3.Itching (allergic).
C.Cornea:
1.Burning.
2.Foreign-body sensation.
3.Considerable discomfort.
4.Reflex photophobic tearing.
5.Blinking exacerbates pain.
6.Pain relieved with pressure holding the lid shut. With a foreign body or a corneal lesion, pain is exacerbated by lid movement and relieved by cessation of lid motion.
D.Sclera:
1.Redness or vessel injection.
E.Uveal tract (uveitis or iritis):
1.Dull, deep-seated ache and photophobia.
2.Profound ocular and orbital pain radiating to the frontal and temporal regions accompanying sudden elevation of pressure (acute angle–closure glaucoma).
3.Vagal stimulation with high pressure may result in nausea and vomiting.
4.Usual history of mild intermittent episodes of blurred vision preceding onset of throbbing pain, nausea, vomiting, and decreased visual acuity.
5.Halos around light.
F.Orbit:
1.Deep pain with inflammation and rapidly expanding mass lesions.
2.Eye movement causing sharp pain due to meningeal inflammation.
G.Sinusitis:
1.Secondary orbital inflammation and tenderness on extremes of eye movement.
Subjective Data
A.Review the onset, duration, and course of symptoms. Inquire regarding the quality of pain.
B.Review any predisposing factors such as trauma or a foreign object. Ask: Was the onset sudden or gradual?
C.Note reported changes in visual acuity or color vision.
D.Note aggravating or alleviating factors.
E.Determine whether the eye pain is bilateral or unilateral.
F.Review history for herpes, infections, and toxic or chemical irritants.
G.Review history for glaucoma and previous eye surgeries or treatments.
H.Assess the patient for any other symptoms such as migraine headache, sinusitis, or tooth abscess.
I.Inquire whether the patient has lost a large amount of sleep, or slept with contact lenses.
J.Inquire whether he or she has been exposed to a large amount of UV light or sunlight (vacation, tanning beds).
K.Review history for any other medical problems such as lupus, sarcoidosis, or inflammatory bowel disease.
Physical Examination
A.Inspect:
1.Evaluate both eyes.
2.Test visual acuity and color vision.
3.Observe for extraocular eye movements (EOMs) and visual fields.
4.Check the eye, lid, and conjunctiva for masses, foreign bodies, and redness.
5.Check pupil reactivity and corneal clarity.
6.Conduct a funduscopic exam for disk abnormalities.
7.Perform ear, nose, and throat exam.
B.Palpate:
1.Palpate lacrimal ducts for drainage.
2.Palpate sinuses for tenderness.
3.Invert upper lid and check for foreign body or chalazion.
4.Palpate the periorbital skin for tenderness.
Diagnostic Tests
A.Fluorescein stain.
B.Measurement of intraocular pressure (IOP).
Differential Diagnoses
A.Eye pain.
B.Hordeolum.
C.Chalazion.
D.Acute dacryocystitis.
E.Irritant exposure.
F.Conjunctival infection.
G.Corneal abrasion.
H.Foreign body or other trauma.
I.Ulcers.
J.Ingrown lashes.
K.Contact lens abuse.
L.Scleritis.
M.Acute angle-closure glaucoma. With acute angle-closure glaucoma, fixed, midposition pupil, redness, and a hazy cornea may be present.
N.Uveitis.
O.Referred pain from extraocular sources such as sinusitis, tooth abscess, tension headache, temporal arteritis, and prodrome of herpes zoster.
P.Iritis.
Q.Bacterial keratitis.
R.Temporal arteritis.
S.Cluster headache.
T.Optic neuritis.
U.Orbital cellulitis.
Plan
A.General interventions:
1.The initial task is to be sure that there is no threat to vision.
2.Treatment modality depends on the underlying cause of eye pain.
B. 
See Section III: Patient Teaching Guide How to Administer Eye Medications.
C.Pharmaceutical therapy: Medication depends on the underlying cause.
Follow-Up
A.Follow-up depends on the underlying cause.
Consultation/Referral
A.Any change in visual acuity or color vision requires an urgent ophthalmologic consultation (same-day referral).
Individual Considerations
A.Geriatrics:
1.Common pain medications for geriatric eye pain:
a.Volatren 0.1% solution or Acular 0.5%–one drop three to four times a day (maximum 2 weeks). Caution bleeding risk secondary to NSAID classification.
b.Akten lidocaine ophthalmic gel 3.5%–two drops to ocular surface; or Tetracaine 0.5% eye drops one drop to ocular surface. These anesthetic medications are usually implemented in-clinic for severe pain or applied prior to an ocular procedure/surgery.