Eye Pain

Eye pain can have a variety of causes.

1. Eye pain is often described as burning, sharp, shooting, dull, gritty, a feeling of "something in my eye," aching, pressure, boring, throbbing, or stabbing. People sometimes confuse pain originating from the eye with other symptoms, such as a headache, sinus pain, toothache, or a migraine.
2. Seek emergency medical care for eye pain if you've experienced a chemical or flash burn, a traumatic event, or have accompanying vision loss.
3. Treatment depends upon the cause of the eye pain.

Eye pain is a very common reason for people to seek medical care from their family doctor or an ophthalmologist, a medical doctor specializing in the diagnosis and treatment of eye diseases.

Causes of eye pain fall into two broad categories: ocular pain and orbital pain.

• Conjunctivitis is one of the most common eye problems. Conjunctivitis can be an allergic, chemical, bacterial, or viral inflammation of the conjunctiva (the delicate membrane lining the eyelid and covering the eyeball). Pinkeye is a nonmedical term usually referring to conjunctivitis caused by a respiratory virus, because the conjunctiva gets inflamed and turns a pinkish color. Conjunctivitis is usually not associated with the symptom of pain. Itching, redness, and drainage are typical symptoms and signs associated with conjunctivitis.
• Corneal abrasions and corneal ulcerations are common conditions that cause eye pain. The cornea is the transparent surface of the eye, and it contains many pain-sensitive nerve endings. Abrasions occur from scratches to the surface of the cornea, such as from trauma, a foreign body in the eye, or overuse of contact lenses. Ulcerations occur from primary infections of the cornea or infected abrasions.
• Keratopathies are a variety of conditions of the cornea and can be a cause of ocular pain.
• Foreign bodies, usually located on the cornea or in the conjunctiva, are objects or materials that give the sensation that something is in eye. Foreign bodies produce eye pain similar to that of corneal abrasions.
• Chemical burns and flash burns can be significant causes of eye pain. Chemical burns come from eye exposure to acid or alkaline substances, such as household cleaners or bleach. Flash burns occur from intense light sources when improper or no eye protection is worn while performing arc welding or being exposed to the ultraviolet rays of tanning booths. Even an intense sunny day can cause a corneal flash burn from reflected ultraviolet light.
• Blepharitis is a condition that causes mild eye discomfort when plugged oil glands at the eyelid edges cause inflammation of the eyelid.
• A sty or a chalazion causes eye pain because of local irritation. Either of these conditions cause a lump you can see or feel within the eyelid. The lump is a result of a blocked oil gland within the eyelid. This lump causes irritation to the eye, can be very painful to the touch, and may occur in both children and adults.
• Acute angle closure glaucoma can cause severe ocular or orbital pain. However, most cases of glaucoma are of the open-angle variety and are painless. An increase in intraocular pressure, or internal eye pressure, causes glaucoma. This can ultimately lead to defects in vision and even blindness if left untreated. Intraocular pressure can increase because of a blockage of outflow or increased production of aqueous humor (the fluid that bathes the inner eye). Glaucoma typically occurs in older adults.
• Iritis is an inflammation of the iris, or colored part of the eye, that causes one to feel deep eye or orbital pain, usually accompanied by blurred vision and light sensitivity.
• Scleritis is a rare cause of severe eye pain and is often associated with systemic illness.

Orbital pain is described as a deep, dull ache behind or in the eye. This pain is often caused by diseases of the eye.

• Optic neuritis is an inflammation of the optic nerve. The optic nerve connects to the back of the eye. The cause of this inflammation can be from multiple sclerosis, viral infections, or bacterial infections and can cause symptoms such as pressure behind the eye together with changes in vision and eye pain, especially on movement of the affected eye.
• Sinusitis, which is a bacterial or viral infection or allergic reaction in the sinuses, can cause a sensation of orbital or eye socket pain. Pain coming from the sinus cavities can be interpreted as eye pain.
• Migraines and cluster headaches are a very common cause of orbital eye pain.
• Painful ophthalmoplegia is the combination of orbital pain and eye muscle weakness. In addition to pain, there is double vision when both eyes are open. Causes include various inflammatory conditions of the orbit.
• Tooth pain resulting from problems with the upper teeth may present as pain in the orbit or below the eye.
• Traumatic events, such as a penetrating injury to the eye, a blow to the eye with a foreign object, and motor vehicle collisions, are causes of significant eye pain and injury. Scratches to the cornea typically associated with traumatic events are very painful. These are common eye problems that lead people to seek medical attention.

Pain is a variable measure. Each person may interpret pain differently. Discomfort in the temple area or the forehead is often due to tensing of the facial muscles after use of the eyes for close work. This is commonly known as eye strain and is usually not associated with any eye disease.

Other symptoms often described by those experiencing pain in and around the eye include the following:

• Partial or complete loss of vision
• Extreme light sensitivity
• Tearing
• Double vision
• Halos (colored circles or halos around lights)
• New floaters (spots, strings, cobwebs, or shadows seen before the eyes)
• Limitation of normal eye movement
• Pain with movement of the eye in different directions
• Sensation of flashes or streaks of light
• Severe headache associated with eye pain

All of these symptoms should seek a prompt evaluation from an ophthalmologist or other medical professional.

A doctor or an ophthalmologist may see the following signs as evidence of eye problems:

• Redness of the white of the eye (conjunctiva)
• Chemosis (swelling of the conjunctiva)
• Redness that flares out and surrounds the colored part of the eye (iris)
• Irregular shape of the pupil
• Bulging or protrusion of the eye
• Swelling or redness of the surrounding eye tissue, including the eyelids
• Blood or pus inside the front of the eye (over the colored part of the eye)
• Eye discharge, excessive tearing, crusting, or eyelids stuck together (especially upon awakening)
• A scratch to the cornea or eyeball
• Tenderness of the inner corner of the eye or side of the nose
• Hyphema (blood located within the anterior chamber [front] of the eye)
• Proptosis (the eye appearing to bulge forward within the eye socket)
• Limitation of movement of the eye

If one has eye pain, seek advice from a health care provider or an ophthalmologist. It is difficult over the phone for a health care professional to grade the severity of eye pain or make a diagnosis without examining the patient.

Because of the specialized nature of the equipment necessary for eye examination, most eye problems are usually handled best in an ophthalmologist's office. If your ophthalmologist is not available, go to a hospital's emergency department. If the emergency department has the necessary eye equipment, an ophthalmologist may see you in the emergency department after hours.

• Any eye pain related to burns (chemical or flash) needs immediate treatment.
• Eye pain associated with loss of vision, loss of eye movement, painful eye movement, eye swelling, eye discharge, and severe headache are all significant findings that need to be evaluated by an ophthalmologist or in the emergency department immediately.
• Any eye pain related to a traumatic event such as an object puncturing the eye, a blow to the eye with a foreign object, or a motor vehicle collision with injuries affecting the eye needs to be evaluated by an ophthalmologist or in the emergency department immediately.

• Is there any sign of damage to the eye?
• Is there any possibility of permanent vision loss?
• What type of follow-up is necessary to make certain my eye heals properly?

Medical evaluation of eye pain begins with a thorough history and physical examination. The history consists of questions documenting the symptoms in detail.

• Important questions that should be asked and answered include when the pain started, the location of pain, the intensity of the pain, the duration of pain, the characteristics of pain, any factors that make the pain better or worse, what activities was one engaged in when the symptoms began, history of contact lens use, and previous eye injuries or surgeries.
• Other important questions are whether one has allergies to medications, one's current medications, past medical history, past surgeries, family history, and social history (including work and travel habits as well as any history of alcohol, tobacco, or illegal drug use).
• The physical examination pertaining to the eyes may first consist of checking vision, visual inspection of the eye and its surrounding tissue, and examining eye movements, visual fields (peripheral vision), and the pupil's reaction to light.
• The ophthalmologist may use instruments to get a better look at the internal structures of the eye.
  • An ophthalmoscope, which is a special tool for visualizing the eye, examines the back of the eye and views the surface of the optic nerve (optic disc) and blood vessels.
  • A slit lamp is a microscope that views the surface of the eye up close and in detail to evaluate for possible corneal abrasions and ulcerations. It can also look into the anterior chamber, which is the area between the surface of the eye and the pupil.
  • Eye pressure can be checked using a tonometer on the slit lamp or a device known as a Tono-Pen. These two instruments are used if glaucoma is suspected.
  • The ophthalmologist may also put an anesthetic drop into the eye for both diagnostic and therapeutic purposes. This test helps to determine if the eye pain comes from the surface of the eye or from deeper structures in the eye. In most case of pain originating from the surface of the eye, the pain can be relieved by the topical anesthetic.
  • A yellow-green dye called fluorescein may be put into the eye to detect abrasions, ulcerations, or any corneal defect. A special blue light will be used in conjunction with the fluorescein to check for these problems.

Seek medical attention if one has eye pain.

• Most commonly, home care consists of flushing the eye with water. With exposure to a foreign body or chemical to the eye, it is important to thoroughly flush the eye with lukewarm tap water or commercially prepared eyewash solution. See the home care section under eye injury for techniques on how to flush the eye with water.
• If one suspects a foreign body in the eye, do not rub the eye. This can seriously damage the eye by causing more damage to the surface as the foreign body is moved around with rubbing. Do not attempt to remove a foreign body from the eye or someone else's eye. Treatment other than gentle eye irrigation is generally not recommended and should be reserved for medical professionals and eye doctors.
• For mild cases of eye discomfort, rest the eyes, take over-the-counter pain relievers such as ibuprofen (Advil) or acetaminophen (Tylenol), and avoid bright light.

Treatment at the ophthalmologist's office or at an emergency department will vary widely, from giving one instructions to apply warm compresses for a sty or a chalazion to taking one into emergency surgery for acute glaucoma.

• Conjunctivitis: Antibiotic eyedrops or eye ointment treat the bacterial form. Viral conjunctivitis (pinkeye) is typically treated in a similar manner as bacterial conjunctivitis, because it may be difficult to tell the difference between bacterial versus viral infections. Antihistamines, in the form of drops with or without oral agents such as diphenhydramine (Benadryl) or non-sedating antihistamines, normally treat allergic conjunctivitis.
• Corneal abrasions and ulcerations: Antibiotic eyedrops (to prevent infection), eye ointment, and pain medication treat these.
• Foreign body in the eye: There are different techniques to remove foreign bodies: irrigation with eye wash, removal with a cotton tip applicator, removal with a small needle, or removal with an ophthalmologic drill. After foreign body removal, there may be an abrasion or a rust ring (rust from a metal foreign body), which would be treated separately.
• Chemical eye burns and corneal flash burns: Chemical eye burns are treated immediately with anesthetic eye drops and great amounts of water to wash out the eye until normal levels of acid or alkali of the eye are reached. The acid or alkali levels will be checked with a special paper called pH paper. After thorough washing is complete and the pH is normal, evaluation by an ophthalmologist is required for further treatment, depending on the extent of the chemical burn. Flash burns are treated as many small abrasions with antibiotic eyedrops, eye ointment, and pain medication. Typically, follow-up with an ophthalmologist is recommended.
• Blepharitis: The patient will be instructed to scrub the eyelid edges with mild shampoo like baby shampoo on a soft washcloth twice a day to remove excess oil.
• Styes or chalazions: These can initially be treated conservatively by placing warm compresses, such as a washcloth that has been warmed with hot water, on the eye or eyes for 15 to 20 minutes, four times a day. An antibiotic ointment can be applied. If the hordeolum (stye) becomes more painful, the ophthalmologist may open it up so the infection can drain out. If a chalazion does not go away in three to four weeks, it may be removed surgically through an incision on the inside of the eyelid.
• Glaucoma: Acute glaucoma has many treatment options depending on the type, severity, and duration of the attack. Severe glaucoma can be a true eye emergency with permanent eye damage occurring within several hours. Treatment typically begins with eyedrops containing a topical beta-blocker (for example, timolol [Timoptic]), a topical steroid drop, and a pupillary constricting eyedrop; other medicines may be given intravenously or in pill form. If these treatments fail to decrease intraocular eye pressure, surgery may be considered.
• Iritis: This condition may be treated with eyedrops that cause the pupils to dilate (get bigger) and with topical steroid eyedrops. In severe cases of iritis, oral steroids or other anti-inflammatory agents may be used.
• Optic neuritis: Gradual loss of vision and painful eye movement are consistent with a diagnosis of optic neuritis. All cases need to be diagnosed and treated. Most commonly, a thorough work-up needs to be performed with both ophthalmologists and neurologists to determine the cause of optic neuritis.
• Sinusitis: When sinusitis is determined to be a result of bacterial infection, it can be treated with antibiotics.
• Migraines: When migraine headaches cause eye pain, both can be treated with routine over-the-counter medications, such as ibuprofen (Motrin) and acetaminophen (Tylenol), as well as with prescription anti-migraine medications.
• Traumatic events to the eye: Penetrating injuries to the globe of the eye are always best managed by ophthalmologists and require immediate evaluation in the emergency department.

Follow-up care usually depends on the severity of the eye problem.

Signs and symptoms to look for are the same as the signs and symptoms of any of the eye injuries or diseases. Return to the ophthalmologist or the emergency room if increased eye pain, any sight problems, increased eye discharge or redness, or swelling around the eye occurs.

Prevention of common causes of eye pain starts with eye protection.

• Wear goggles while working with hand tools, power tools, industrial chemicals, or when there is a chance of getting chemicals, debris, or small particles in the eye.
• Wear safety glasses while playing sporting activities, such as basketball, racquetball, and tennis. Also, appropriate headgear should be worn, such as a safety helmet at work when needed, a helmet for playing baseball, and a face mask for playing hockey.
• When using potent chemicals, such as cleaning fluids, ammonia, and detergents, read the instructions carefully. Also, when using spray chemicals, it is always important to point the nozzle away from the eyes at all times.
• Children at play often sustain eye injuries. These injuries can result from spring-loaded toys that shoot darts and other objects, plastic swords, and BB guns. Young children can also injure their eyes as a result of fireworks mishaps. Close parental supervision can often prevent these injuries.
• Prevent eye injuries while performing gardening and lawn care activities by picking up rocks and sticks before mowing and watching for low-hanging branches and trees while mowing. When walking, running, or skiing in the woods, beware of branches that could injure the eye.
• If one wears contact lenses, use proper routine eye care to prevent contact lens-related eye injuries. People who wear contact lenses should follow their eye doctor's instructions carefully for removing, applying, and washing their contact lenses.

The prognosis for corneal abrasions is good.

Pain associated with corneal ulcers, infections, chemical burns, and penetrating eye injuries has a much more guarded outlook.

Blepharitis tends to be a chronic problem and eyelid hygiene should be maintained.

American Academy of Ophthalmology
655 Beach Street
Box 7424
San Francisco, CA 94120
Phone: 415-561-8500