Hospital Medicine

Ocular pain

Ocular pain

I. Problem/Condition.

Eye pain is a myriad of symptoms ranging from sharp pain in the eye to mild discomfort or itching in the eyes. As the spectrum of symptom presentation varies with eye pain, the cause of these pains may vary from very simple refractive errors to potentially sight threatening disorders like glaucoma and uveitis.

A feeling of discomfort or pain in the eye can be caused by a problem in the eye itself. It can also be caused by a problem involving any of the structures around the eye or referred pain from tissues with similar innervation as ocular tissues (V1). Patients with eye pain or peri-orbital pain frequently present to primary care physicians, neurologists or ophthalmologists.

Most ophthalmologic conditions producing ocular pains are associated with obvious ocular symptoms and signs like red eye, photophobia, vision loss or diplopia. Sometimes it poses a challenge to physicians when the pain is associated with a quiet eye or “white eye”.

II. Diagnostic Approach.

A. What is the differential diagnosis (DDx) for this problem?

For simplicity we can differentiate the differentials in two broad headings:

  • Ocular pain with eye diseases.

  • Ocular pain without primary eye disease.

A. Ocular Pain with Primary Eye Diseases:

This broad category can further be subdivided into with red eye or without red eye.

DDx with Red Eye:

  • Disorders of lid and adenexa: Acute dacrocytitis, stye, hordeolum internum.

  • Disorders of cornea: Corneal abrasions, corneal ulcers, corneal perforations.

  • Disorders of episclera and sclera: Acute episcleritis and scleritis.

  • Disorders of the conjunctiva: Viral or allergic conjunctivitis.

  • Disorders of uvea: Acute anterior uveitis.

  • Disorders of angle: Acute angle closure glaucoma.

DDx without Red Eye:

  • Chronic open angle glaucoma (OAG).

  • Posterior scleritis.

  • Intraocular or orbital tumor.

  • Optic neuritis, retrobulbar neuritis, papillitis.

  • Orbital myositis.

  • Refractive errors.

B. Ocular pain without primary eye disease:

  • Ocular migraine.

  • Giant cell arteritis.

  • Trigeminal neuralgias.

  • Raeder paratrigeminal syndrome.

  • Postherapeutic neuralgias.

  • Gradenigo's syndrome.

  • Cavernous sinus and superior fissure processes.

  • Carotid artery dissection.

  • Carotidynia.

1. Historical information important in the diagnosis of this problem.

A complete ocular history should be obtained in all cases of ocular pain which must include any prior visual loss, previous ophthalmic diseases, use of contact lenses, last refractive check ups, remote or recent ocular surgeries, any recent or remote ocular trauma. Patients who have eye pain must be asked about the onset, duration, nature, timing and frequency of the pain.

The main focus of the history should not only be limited to differential diagnosis of the problem, but also to determine the group of patients who need immediate referral to an ophthalmologist. Below are red flag signs and symptoms which a hospitalist or internist must be aware of while making an informed decision to refer to an ophthalmologist:

  • Recent sudden vision loss, loss of visual fields.

  • Relative afferent pupillary defects (RAPD).

  • Diplopia.

  • Red eye with chemosis of conjunctiva.

  • Hyphema or hypopyon.

  • Recent intra or extraocular surgery.

  • Proptosis.

  • Recent trauma.

  • Loss of fundus red reflex.

  • Corneal opacity or haziness.

  • Lid retraction or ptosis.

Patients who had recent surgery in the eye may be present with pain suggestive of intraocular infection (endophthalmitis), inflammation (uveitis or retinitis) or increased intraocular pressure (post-operative glaucoma). All of these conditions require immediate referral to the ophthalmologist to prevent sight threatening complications from these disorders.

2. Physical Examination maneuvers that are likely to be useful in diagnosing the cause of this problem.

Frequently, patients with eye pain present to a primary care physician, hospitalist or a neurologist who have limited access to higher end ophthalmic diagnostic instruments. Fortunately, most of the basic eye examination for ocular pain can be performed by the internist or hospitalist with minimum equipment (hand light, near vision card and direct ophthalmoscope).

Visual acuity must be recorded as the best correct acuity, which means with any kind of refractive correction the patient might be using like glasses or contact lenses. Vision of eye must be tested independently and also combined and recorded. Simple bedside visual fields can be tested using the confrontational method using the examiners visual field as the reference. Hand light examinations can reveal any abnormality in conjuctiva, corneal haze, abnormality in pupillary size and reaction to light. Hand light examination is sufficient most of the time to detect any conjunctival chemosis, corneal edema or haziness, anterior chamber abnormalities, and also any abnormality of the pupil or iris.

Direct ophthalmoscopic examinations can give an idea about the optic nerve, vitreous humor, central retina and would be sufficient to exclude gross optic atrophy or papilledema. For detailed examinations of the posterior segment an ophthalmologist referral is always advised.

Detailed diagnosis and clinical features of the conditions causing eye pain is beyond the scope of discussion here. We will be discussing in brief about some common conditions which can cause ocular pain.

Stye:

It is an acute inflammation of the sebaceous gland of the lids namely the gland of Zeiss and Moll. Any cause that leads to blockage in the secretion of these glands leads to inflammation and infection of the sebaceous contents leading to a painful eye condition known as stye.

It typically presents as an inflamed red swelling at the eyelid margins more common in upper eye lids than the lower. Almost always it is associated within the eyelash root. Recurrent stye can be an indication of uncorrected refractive errors in children and can be a more ominous sign of diabetes mellitus in patients with other characteristics of the disease. Simple procedures like hot water fomentations or manual removal of the eyelash leads to expression of the contents leading to healing.

Glaucoma:

Glaucoma can cause acute or chronic ocular pain. It is characterised by optic nerve damage associated with increased intraocular pressure leading to visual field loss. The two forms of glaucoma could be open angle and angle closure glaucoma. As the name suggests, the open angle glaucoma is associated with a wide open angle but with a problem in filtration of the aqueous through the angle. Angle closure glaucoma is associated with a narrow angle leading to mechanical obstruction in the drainage of the aqueous humor.

Open angle glaucoma can be associated with other conditions (secondary glaucoma) like inflammations of the uvea (uveitis) leading to obstruction of the aqueous outflow. Open angle glaucoma has a very insidious onset leading to a chronic ocular pain and slow but extensive damage of the optic nerve and loss of visual field.

In contrast, acute angle closure glaucoma presents with sudden onset of eye pain and loss of vision. The pain may be diffuse, in or around the eye, or may present as headache sometimes confused with migraine. Patients with acute angle closure glaucoma, present with sudden attack of ocular pain, nausea with vomiting, decrease or loss of vision with some colored haloes.

Colored halos are a classical symptom of acute angle closure glaucoma and represents corneal edema secondary to increased intraocular pressure. The pupils may be mildly dilated and react poorly to light. Patients might complain of photophobia associated with this. These patients are often not difficult to diagnose and should immediately be referred to an ophthalmologist for better care. Opening the angle with a laser iridotomy may be sight saving in these conditions. But if an immediate ophthalmologist referral is unavailable then pilocarpine drops may be used to constrict the pupil leading to opening of the angle.

Corneal Pathologies:

Corneal disorders that cause eye pain are mostly epithelial problems and the pain is often described as "scratchy" or a "foreign body" sensation. These symptoms are often associated with conjunctival congestion around the cornea (circum corneal congestion) and watering of the eyes. This epithelial defect can usually occur from trauma, improper use of contact lens or corneal ulcers secondary to infections. Tearing, redness, corneal opacity and conjunctival congestion needs urgent ophthalmologic referral in these cases.

Staining the cornea with topical flourescein and examination under a cobalt blue light is very useful to demonstrate the corneal epithelial defects. Most simple corneal abrasions are self limiting within 24 to 48 hours and need patching of the eyes for comfort and healing of the eye.

Uveitis:

Uveitis can be classified as anterior (if involves the iris or ciliary body) or posterior uveitis (choroid). Most anterior uveitis presents with ocular pain, decreased vision, photophobia and lacrimation. A slit lamp examination is useful to detect the anterior segment inflammation characterized by aqueous cells and flare. White cells may layer the anterior chamber in uveitis forming a hypopyon. Hypopyon can be a sign of severe infection (endophthalmitis) or inflammation. Uveitis can be primary idiopathic or can be a cause of systemic inflammatory process (HLA B-27 associated disorders, SLE, Rheumatoid arthritis, Behcet's Disease or sarcoidosis). Patients with signs of uveitis should be referred to an ophthalmologist.

Scleritis/Episcleritis:

Scleritis may be associated with significant photophobia, tearing, focal tenderness to palpation, and visual loss. The pain of scleritis often is localized to the eye but may radiate to other locations like temple, sinuses or behind the eyeball. Scleritis may affect the anterior or posterior segments of the eye. Patients who have anterior scleritis typically have visible eye redness, injection, or a nodule of inflammation. Patients with posterior scleritis usually have ocular pain with a "white eye". These disorders might be difficult to diagnose as they involve the posterior segments and need careful examination by an ophthalmologist with the help of an indirect ophthalmoscope.

Orbital computed tomography (CT) scan may show thickening of the sclera and inflammation leading to the diagnosis. These patients should be referred to an ophthalmologist.

3. Laboratory, radiographic and other tests that are likely to be useful in diagnosing the cause of this problem.

Radiographic modalities are very useful in determining some causes of ocular pain accurately. The least expensive method includes a plain radiograph of the sinus and the orbit. Though it might be a very simple and inexpensive test, it might give a preliminary evidence to diagnose certain conditions causing eye pain more effectively. For example a recent history of ocular trauma or chisel and hammer injury can show a radio opaque intraocular foreign body in a plain orbital radiograph. A sinus radiograph may indicate sinusitis as the cause of ocular pain in some young patients.

A CT scan of the orbit and eye ball can differentiate many important causes of ocular pain. An intraocular foreign body can be better delineated by a CT scan than a plain radiograph. A CT scan can also diagnose any vitreous hemorrhage and retinal detachment associated with ocular trauma when ophthalmoscopic examination is limited secondary to poor visualization through the vitreous. CT scan can also diagnose proptosis, intraorbital tumors, extraocular muscle abnormalities and any other orbital pathology causing the symptoms of eye pain.

Magnetic resonance imaging (MRI) of the orbit is better in diagnosing these conditions than CT scan. An MRI is contraindicated if one suspects a metallic foreign body as the cause of the eye pain. Therefore a CT scan of the orbit is a must before an MRI in patients with suspected ocular trauma.

III. Management while the Diagnostic Process is Proceeding.

A. Management of Clinical Problem Ocular Pain.

Management of ocular pain is based on the diagnosis of the disorder causing the ocular pain. Hospitalist and internists can manage simple ocular pain very effectively, but must be aware of the situations which need urgent or emergent referral to an ophthalmologist.

IV. What's the Evidence?

Cronau, H, Kankanala, RR, Mauger, T. "Diagnosis and management of red eye in primary care". Am Fam Physician. vol. 81. 2010. pp. 137-144.

(Review covers approach to painful red eye.)

Fiore, DC, Pasternak, AV, Radwan, RM. "Pain in the quiet (not red) eye". Am Fam Physician. vol. 82. 2010. pp. 69-73.

(Review is complementary to the above article in covering pain in the ‘white’ or non-red eye. It provides a very nice algorithm.)

Dargin, JM, Lowenstein, RA. "The painful eye". Emerg Med Clin North Am. vol. 26. 2008. pp. 199-216.

(A comprehensive, in-depth writing of each prominent cause of painful eye.)

Lee, AG, Al-Zubidi, N, Beaver, HA, Brazis, PW. "An Update on Eye Pain for the Neurologist". Neurol Clin. vol. 32. 2014. pp. 489-505.

(Review article giving a nice collection of algorithms and approaches to painful eye. Addresses more of the non-ophthalmologic causes in-depth.)

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