Eye pain

Last updated: April 3, 2025

Summary

Eye pain presents a diagnostic challenge due to the wide range of possible causes requiring quick risk stratification and appropriate action. Causes are generally diagnosed clinically and include include traumatic injury, inflammatory and/or infectious conditions, and other (e.g., neurological) conditions. Vision-threatening causes must be urgently ruled out. Assessment begins with a focused history, including both ophthalmologic and relevant nonophthalmologic symptoms, medical history (e.g., contact lens use, autoimmune conditions), and past surgeries. A focused ophthalmologic examination is then performed, which includes many aspects of the comprehensive eye examination (e.g., visual acuity, examination of the extraocular muscles, and slit-lamp examination). The diagnosis is narrowed based on clinical findings, and condition-specific diagnostics and treatment are initiated. Vision-threatening causes of eye pain require urgent ophthalmology consultation, while most non-vision-threatening causes may be followed up with outpatient ophthalmology.

Etiology

Etiologies of eye pain can be categorized by immediate threats to vision, underlying mechanism, and eye redness.

Vision-threatening causes ^[1]

Traumatic

Vision-threatening traumatic injuries are frequently associated with eye redness.

Inflammatory and/or infectious

Inflammatory and/or infectious vision-threatening causes of eye pain generally manifest with a red eye.

Other

Non-vision-threatening causes ^[1]

Traumatic

Red eye
Non-red eye
- Eyelid laceration
- Lacrimal duct laceration

Inflammatory and/or infectious

Red eye
- Photokeratitis
- Keratoconjunctivitis
- Inflamed pinguecula
Non-red eye

Conjunctivitis, blepharitis, episcleritis, and allergic contact dermatitis are typically painless but can manifest with discomfort if inflammation is severe.

Other

Red eye: Keratoconjunctivitis sicca (dry eye disease)
Non-red eye
- Orbital tumor
- Intracranial tumor

Cluster headaches and certain types of migraines can manifest with pain localized to the eye (see “Mimics”).

Initial management

Approach

Perform a focused clinical evaluation to narrow the diagnosis and localize the lesion (see “Clinical evaluation”).
Begin critical interventions immediately as indicated, e.g.:
- Acute management of traumatic eye injuries (including open globe injuries)
- Treatment of acute angle-closure glaucoma
- Lateral canthotomy and cantholysis in orbital compartment syndrome
- Immediate large-volume irrigation of ocular chemical burns
- Corneal foreign body removal
Consult ophthalmology urgently for vision-threatening causes of eye pain or red flags for painful red eye.
Administer analgesia as indicated, e.g., analgesia for corneal pain
Obtain additional diagnostics as indicated and initiate condition-specific treatment.

Red flags for painful red eye ^[3]

Moderate to severe eye pain
Visual impairment
Red flags for serious eye injury (e.g., ocular chemical burn, penetrating eye injury)
Opacification or visible defect of the cornea
Irregular pupil
Impaired pupillary reflex
Ciliary flush

Clinical evaluation

Focused history ^[1]^[2]

Ophthalmologic

Symptom onset
Character of pain (e.g., burning, dull, sharp, foreign body sensation)
Presence or absence of eye redness
Visual disturbances
- Changes in visual acuity or vision loss
- Visual field defects
- Diplopia
- Changes in color vision
Photophobia
Discharge or crusting
Eyelid swelling
Mechanism of injury, if applicable
Recent ocular surgery
New ocular medications
Contact lens hygiene
- Wear schedule (e.g., sleeping in contact lenses, overnight wear)
- Factors increasing contamination risk
  - Wearing lenses past the expiration date
  - Rinsing lenses in tap water and/or improper storage
  - Swimming or hot tub use while wearing lenses

Nonophthalmologic

Fever
Headache
Concurrent neurological symptoms
Jaw claudication
Skin lesions (e.g., periorbital erythema, vesicular rash)
History of:
- Systemic diseases (e.g., multiple sclerosis, Sjogren syndrome)
- Immunocompromise
- Allergies

Focused physical examination ^[1]^[2]

Diagnosis

Most conditions causing eye pain are diagnosed clinically; laboratory testing and imaging are indicated in select cases.

Laboratory testing ^[1]

Diagnostics for giant cell arteritis: e.g., ESR, CRP
Urgent diagnostics for trauma patients
Additional diagnostics as requested by ophthalmology

Imaging ^[1]^[2]

CT head and/or orbits
- Penetrating trauma and/or foreign body
- Orbital cellulitis (for confirmation and/or to assess for complications such as abscess)
MRI
- Suspected neurological cause: e.g., optic neuritis, intracranial tumor
- Contraindicated if a metallic foreign body is suspected
Ocular POCUS
- May be useful for assessing suspected penetrating eye injury or intraocular foreign body
- Contraindicated if open globe injury is suspected

Common vision-threatening causes

Common vision-threatening causes of eye pain ^[1]
	Characteristic clinical features	Diagnostic findings	Management
Traumatic eye injuries ^[4]^[5]^[6]	Vary by type of trauma Periocular ecchymosis Ocular motility dysfunction Vision changes Abnormal pupil See “Clinical features of traumatic eye injuries” for details.	Clinical diagnosis CT: fractures, foreign bodies, intraocular injury Ultrasound: lens dislocation, foreign bodies, retrobulbar hemorrhage	See “Approach to traumatic eye injuries.”
Orbital compartment syndrome ^[7]^[8]	Proptosis Periorbital swelling Firm globe resistant to digital retropulsion Ophthalmoplegia and/or diplopia	Clinical diagnosis Relative afferent pupillary defect (RAPD) Tonometry: elevated intraocular pressure (IOP) Fundoscopy: papilledema, venous congestion, retinal artery pulsation	Lateral canthotomy and cantholysis See “Treatment” in “Orbital compartment syndrome.”
Orbital cellulitis ^[9]^[10]	Pain, swelling, and/or erythema Systemic signs of infection (e.g., fever, malaise) Red flags for orbital cellulitis	Clinical diagnosis CT orbits and sinuses with contrast may show an orbital abscess or foreign bodies.	IV antibiotics and/or antifungals See “Management” in “Orbital cellulitis.”
Endophthalmitis ^[11]^[12]	Acute vision loss Conjunctival hyperemia and chemosis	Clinical diagnosis RAPD Fundoscopy: reduced or absent red reflex Slit-lamp examination: hazy cornea or aqueous chamber; hypopyon	Intravitreal and IV antibiotics and/or antifungals See “Treatment” in “Endophthalmitis.”
Acute angle-closure glaucoma ^[13]^[14]	Sudden onset Unilateral firm, red eye; ciliary flush Midsized, unresponsive pupil Halos around light sources Decreased visual acuity; loss of peripheral vision Nausea and vomiting	Clinical diagnosis Tonometry: elevated IOP (> 21 mm Hg) Slit-lamp examination: shallow anterior chamber, hazy cornea	Urgent reduction of IOP See “Acute management checklist for acute angle-closure glaucoma.”
Optic neuritis ^[15]^[16]	Reduced visual acuity Subacute vision loss Visual field defects, dyschromatopsia Retrobulbar pain that worsens with eye movement	Clinical diagnosis RAPD MRI head and orbits: optic nerve enhancement	Neurology consultation High-dose glucocorticoid therapy See “Treatment” in “Optic neuritis.”
Cranial giant cell arteritis (GCA) ^[17]^[18]	Headache typically over the temples Tender temporal artery Jaw claudication Vision loss: scotoma, amaurosis fugax Diplopia Constitutional symptoms (e.g., fever, weight loss)	ESR ≥ 50 mm/hour CRP ≥ 10 mg/L Thrombocytosis Duplex ultrasound: vessel wall thickening, stenosis, or occlusion; noncompressible artery	High-dose glucocorticoid therapy Rheumatology consultation See “Treatment of GCA.”
Herpes zoster ophthalmicus ^[19]	Painful erythematous vesicular rash in the ophthalmic nerve dermatome Fever, headache, fatigue Conjunctival injection, chemosis, photophobia Impaired vision Hutchinson sign of the nose	Clinical diagnosis Slit-lamp examination with fluorescein staining: punctate or pseudodendritic corneal lesions	Antiviral therapy for herpes zoster See “Treatment” in “Herpes zoster ophthalmicus.”
Bacterial keratitis ^[20]	Red eye, photophobia, blurry vision Foreign body sensation Purulent discharge History of contact lens use	Clinical diagnosis Slit-lamp examination: hypopyon Fluorescein staining: round corneal ulcer or infiltrate	Topical broad-spectrum antibiotics See “Treatment” in “Bacterial keratitis.”
Herpes simplex keratitis ^[21]	Typically unilateral Red eye, photophobia, blurry vision Foreign body sensation Corneal hypesthesia	Clinical diagnosis Fluorescein staining: superficial dendritic ulcers	Topical or oral antivirals See “Treatment” in “Herpes simplex keratitis.”
Corneal ulcer ^[22]	Often a complication of keratitis Foreign body sensation Epiphora, conjunctival injection Blurry and/or decreased vision	Clinical diagnosis Slit-lamp examination: corneal epithelial defect, stromal edema, cells and flare	Treatment of underlying cause (e.g., topical antibiotics or antivirals) See “Management” in “Corneal ulcer.”
Corneal foreign body ^[23]	Sudden onset of symptoms, often after a triggering event Epiphora, photophobia, foreign body sensation Blurred vision Difficulty keeping eye open	Slit-lamp examination and/or eversion of the upper eyelid: visible foreign body, rust rings, corneal defect Positive Seidel test indicates open globe injury. CT or ultrasound orbit: foreign body	Corneal foreign body removal Tetanus prophylaxis and antibiotics as indicated See “Management” in “Corneal foreign body.”
Anterior uveitis ^[24]^[25]	Dull periocular pain Red eye, photophobia, blurry vision Epiphora Ciliary injection	Clinical diagnosis Slit-lamp examination: cells and flare, hypopyon	Supportive care (e.g., topical corticosteroids or cycloplegics) Treatment of underlying cause See “Management” in “Uveitis.”

Orbital cellulitis Fungal endophthalmitis Acute angle-closure glaucoma Papillitis in optic neuritis Giant cell arteritis Herpes zoster keratitis Herpes zoster ophthalmicus Hutchinson sign of the nose Infective keratitis Herpes simplex keratitis Corneal ulcer Corneal foreign body Corneal rust ring Anterior uveitis

Common non-vision-threatening causes

Common non-vision-threatening causes of eye pain ^[1]
	Characteristic clinical features	Diagnostic findings	Management
Corneal abrasion ^[23]	Foreign body sensation Epiphora, photophobia Conjunctival injection Blurred vision	Clinical diagnosis Slit-lamp examination with fluorescein stain: pattern of abrasive injury consistent with underlying mechanism Pain resolves with local anesthetic	Removal of corneal foreign body Topical antibiotics as indicated See “Management” in “Corneal abrasion.”
Preseptal cellulitis ^[26]^[27]	Eyelid and periorbital swelling and erythema No red flags for orbital cellulitis	Clinical diagnosis CT orbits and sinuses with contrast: soft tissue thickening anterior to the orbital septum	Empiric antibiotics See “Treatment” in “Preseptal cellulitis.”
Dacryoadenitis and dacryocystitis	Localized erythema and tenderness over lower eyelid Possibly, purulent discharge	Clinical diagnosis CT head and orbits to rule out orbital cellulitis and periorbital cellulitis	Treatment of underlying cause (e.g., antibiotics) See “Dacryoadenitis” and “Dacryocystitis.”
Blepharitis ^[28]	Recurring redness, swelling, and/or scaling of the eyelid margins Itchiness Foreign body sensation	Clinical diagnosis	Supportive (e.g., warm compresses, eyelid cleansing) See “Management” in “Blepharitis.”
Hordeolum	Erythematous pustule on the eyelid Eyelid edema	Clinical diagnosis	Supportive (e.g., warm compresses and massage) See “Management” in “Hordeolum.”
Keratoconjunctivitis sicca ^[29]	Dry eye Burning or itching sensation Blurred vision Conjunctival injection	Clinical diagnosis Slit-lamp examination Punctate epithelial erosions Epithelial filaments on the corneal surface	Supportive therapy for conjunctivitis Treatment of underlying cause See “Treatment of keratoconjunctivitis sicca.”
Conjunctivitis ^[30]^[31]	Conjunctival injection Chemosis Burning, itching, foreign body sensation Discharge	Clinical diagnosis	Supportive therapy for conjunctivitis Cause-specific treatment (e.g., pharmacological treatment for allergic conjunctivitis) See “Treatment of conjunctivitis.”

Corneal abrasion highlighted by fluorescein staining Corneal abrasion due to foreign body under the upper eyelid Preseptal cellulitis Acute dacryoadenitis Dacryocystitis Blepharitis External hordeolum Conjunctivitis

Acute management checklist

Perform a focused clinical evaluation, including:
- Eye examination
- Slit-lamp examination
Narrow the diagnosis based on the suspected location of the lesion and characteristic clinical features.
Begin critical interventions immediately as indicated, e.g.:
- Management of traumatic eye injuries
- Treatment of acute angle-closure glaucoma
- Lateral canthotomy and cantholysis in orbital compartment syndrome
- Immediate large-volume irrigation of ocular chemical burns
- Corneal foreign body removal
Consult ophthalmology urgently for the following:
- Red flags for painful red eye
- Vision-threatening causes of eye pain
Obtain additional diagnostics as indicated and initiate condition-specific treatment.

Mimics

Headache and facial pain

Trigeminal neuralgia (involving V1 of trigeminal nerve)
Cluster headache
Migraine
Tension headache
Frontal or ethmoid sinusitis
Postherpetic neuralgia
Referred pain from:
- Otitis media
- TMJ dysfunction
- Dental infection
- Nasal masses

Painless causes of red eye ^[30]

The following conditions are typically painless but can cause eye discomfort when severe.

Viral conjunctivitis
Bacterial conjunctivitis
Allergic conjunctivitis
Conjunctivitis due to irritants (e.g., contact lenses, chlorinated water, dust)
Drug-induced conjunctival hyperemia (e.g., cannabis, prostaglandin analogs) ^[32]
Blepharitis
Subconjunctival hemorrhage
Episcleritis
Conjunctival melanoma
Irritation of pinguecula or pterygium

Painless causes of red eye are typically non-vision-threatening.

Viral conjunctivitis Bacterial conjunctivitis Allergic conjunctivitis Conjunctival melanoma Blepharitis Subconjunctival hemorrhage Episcleritis

Painless eyelid or orbital swelling

Chalazion Hereditary angioedema Graves' ophthalmopathy

Painless visual disturbances

Sudden
- Monocular
- Binocular
  - Occipital stroke (cortical blindness)
  - Posterior reversible encephalopathy syndrome
  - Toxic or metabolic causes (e.g., methanol poisoning)
Gradual
- Cataracts
- Open-angle glaucoma
- Age-related macular degeneration
- Diabetic retinopathy
- Refractive errors (e.g., myopia, hyperopia, astigmatism)
- Retinitis pigmentosa
- Hereditary optic neuropathies (e.g., Leber hereditary optic neuropathy)
- Fuchs endothelial corneal dystrophy

Sudden painless visual loss (especially monocular) is a medical emergency that requires urgent evaluation and in many cases ophthalmology consultation.

Functional vision disorders can manifest suddenly or gradually with monocular or binocular symptoms.

Acute central retinal artery occlusion Central retinal vein occlusion Rhegmatogenous retinal detachment Vitreous hemorrhage Papilledema in non-arteritic anterior ischemic optic neuropathy (NAION) Macular hole Cataract Exudative age-related macular degeneration Proliferative diabetic retinopathy Retinitis pigmentosa

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Eye pain

Summary

Etiology

Vision-threatening causes [1]

Traumatic

Inflammatory and/or infectious

Other

Non-vision-threatening causes [1]

Traumatic

Inflammatory and/or infectious

Other

Initial management

Approach

Red flags for painful red eye [3]

Clinical evaluation

Focused history [1][2]

Ophthalmologic

Nonophthalmologic

Focused physical examination [1][2]

Diagnosis

Laboratory testing [1]

Imaging [1][2]

Common vision-threatening causes

Common non-vision-threatening causes

Acute management checklist

Mimics

Headache and facial pain

Painless causes of red eye [30]

Painless eyelid or orbital swelling

Painless visual disturbances

Vision-threatening causes ^[1]

Non-vision-threatening causes ^[1]

Red flags for painful red eye ^[3]

Focused history ^[1]^[2]

Focused physical examination ^[1]^[2]

Laboratory testing ^[1]

Imaging ^[1]^[2]

Painless causes of red eye ^[30]