Eye pain is a common presentation in outpatient, urgent care, and emergency settings. Causes range from benign to vision-threatening. Family physicians should promptly identify red-flag features that require urgent or emergent ophthalmology referral. A painful eye with vision loss, severe photophobia, proptosis, hyphema, or corneal ulceration is a medical emergency. Patient history should include onset, associated vision changes, contact lens use, trauma, chemical exposure, systemic symptoms, and rheumatologic disease. Physical examination should include evaluation of visual acuity (eg, using a Snellen or Rosenbaum chart), pupillary reactions, and extraocular movements. The eyes should be inspected for redness, discharge, and corneal lesions with fluorescein, if available. Findings of significant photophobia, anisocoria, dendritic corneal lesions, or restricted eye movement should prompt immediate referral. Common emergent causes of eye pain include acute angle-closure glaucoma, orbital cellulitis, infectious keratitis, scleritis, and anterior uveitis. An algorithmic approach that distinguishes urgent vs nonurgent etiologies and ophthalmic vs nonophthalmic causes of eye pain can direct next steps.
Eye pain is a common presentation in outpatient, urgent care, and emergency settings, accounting for an estimated 4.6 million outpatient and 1 million emergency department visits annually in the United States.1 Most of these visits are related to non–vision-threatening conditions. Research has shown that primary care physicians perform relatively poorly in the accurate diagnosis of acute eye conditions; an older study in England reported that only 58% of cases had a diagnosis concordant with ophthalmology.2 Appropriate history and physical examination are critical in distinguishing common, self-limited conditions, such as conjunctivitis, from vision-threatening conditions, such as optic neuritis and uveitis. Table 1 summarizes selected causes of eye pain.3
TABLE 1. Selected Causes of Eye Pain
| Condition | Risk factors | Presentation | Examination findings |
|---|---|---|---|
| Emergent | |||
| Acute angle-closure glaucoma | Family history, older age, use of mydriatic drops, anticholinergic medications, or sulfonamides | Headache, nausea and vomiting, severe pain, eye redness, decreased visual acuity | Dilated, unresponsive pupil; elevated intraocular pressure; erythema |
| Chemical injury | Recent exposure to caustic material (eg, bleach, acid) | Burning sensation, decreased vision | Epithelial defect, erythema |
| Globe rupture | Recent trauma | Foreign body, decreased vision | Decreased visual acuity, pupil irregularity or iris prolapse, subconjunctival hemorrhage |
| Optic neuritis | Autoimmune conditions, multiple sclerosis | Pain with eye movement, subacute monocular vision loss | Possible impaired eye movement, visual field loss |
| Urgent | |||
| Corneal abrasion | Contact lens use, history of trauma | Foreign body sensation, unilateral eye pain, watery discharge | Fluorescein examination demonstrating linear uptake |
| Gonococcal conjunctivitis | Gonococcal infection at another site, high-risk sexual history, neonates | Mucopurulent epiphora | Corneal thinning, erythema, extensive purulent exudate |
| Keratitis | Contact lens use, history of trauma, topical steroid use | Decreased vision, severe eye pain, photophobia | Corneal ulcerations, erythema, vesicles on eyelid and nose in herpes zoster ophthalmicus |
| Scleritis | History of autoimmune disease | Severe pain that is worse at night, possible photophobia | Diffuse erythema, pain with eye movements, watery discharge |
| Uveitis | Autoimmune disease, infection, recent eye surgery or trauma | Blurred vision, eye pain, photophobia | Decreased visual acuity, pupil irregularities |
| Nonurgent | |||
| Allergic conjunctivitis | History of seasonal or environmental allergy, exposure to allergen | Bilateral eye redness and itching, watery epiphora | Conjunctival injection, clear or stringy discharge |
| Bacterial conjunctivitis | Contact lens use | Mucopurulent discharge with matting, possible foreign body sensation | Conjunctival injection, mucoid discharge |
| Viral conjunctivitis | Exposure to sick contacts, preceding viral infection, concurrent pharyngitis | Mild discomfort, initial unilateral involvement that progresses to bilateral involvement, watery epiphora | Diffuse conjunctival injection, possible preauricular lymphadenopathy |
Information from reference 3.
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