Eye Pain: Merck Manual Consumer Version

Eye Pain - Eye Disorders - Merck Manuals Consumer Version https://www.merckmanuals.com/home/eye-disorders/symptoms-of...
MERCK MANUAL
Consumer Version
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Eye Pain
By Christopher J. Brady , MD, Wilmer Eye Institute, Retina
Division, Johns Hopkins University School of Medicine
GET THE QUICK FACTS
Eye pain may be severe and seem sharp, aching, or throbbing, or people may feel only mild irritation of the eye
surface or the sensation of a foreign object in the eye (foreign body sensation). Many causes of eye pain also
cause the eye to look red. Other symptoms may be present depending on the cause of eye pain. For example,
people may have blurred vision, a bulging eye, or pain worsened by bright light.
The cornea (the clear layer in front of the iris and pupil) is highly sensitive to pain. Many disorders that affect the
cornea also affect the anterior chamber (the fluid-filled space between the iris and the inner part of the cornea)
and cause spasm of the muscle that controls the iris (the ciliary muscle). When such spasm is present, bright light
causes muscle contraction and worsening pain.
An Inside Look at the Eye
Causes
Disorders that cause eye pain can be divided into disorders that affect primarily the cornea, disorders of other
parts of the eye, and disorders of other areas of the body that cause pain to be felt in the eye.
Common causes
Corneal disorders are the most common causes of eye pain overall, particularly
Corneal scratches (corneal abrasions)
Foreign objects
However, most corneal disorders can cause eye pain.

A feeling of scratchiness or a foreign body sensation may be caused by a disorder of the conjunctiva (the thin
membrane that lines the eyelid and covers the front of the eye) or of the cornea.
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Some Causes and Features of Eye Pain

Cause Common Features* Tests†
Disorders that affect the cornea primarily
Usually affecting both eyes
Eye ache and a feeling of grittiness in
Contact lens keratitis (inflammation of
the eye
the cornea—the clear layer in front of
Eye redness, tearing, and sensitivity to A doctor's examination
the iris and pupil—caused by wearing
light
contact lenses for long periods of time)
In people who wear contact lenses for
long periods of time
Symptoms that begin after an eye
injury, which may not be noticed in
infants and young children
Corneal scratch (abrasion)
Pain in the affected eye when blinking A doctor's examination
A foreign object (body)
and a foreign body sensation
Eye redness, tearing, and usually
sensitivity to light
Often a grayish patch on the cornea
that later becomes an open, painful
sore
A doctor's examination
Eye ache and a foreign body sensation
Culture of a sample taken
Corneal ulcer Eye redness, tearing, and sensitivity to
from the ulcer, done by an
light
ophthalmologist
Sometimes in people who have had an
eye injury or who have slept with their
contact lenses in
Usually in both eyes
Epidemic keratoconjunctivitis (Pink the eye
Eye—inflammation of the conjunctiva, Eye redness, tearing, and usually
the membrane that lines the eyelids sensitivity to light A doctor's examination
and covers the front of the eye, and the Often eyelid swelling and swollen,
cornea caused by an adenovirus) tender lymph nodes in front of the ears
Rarely temporary, severe blurring of
vision
Usually affecting only one eye
Early: Symptoms that begin after an
episode of conjunctivitis
Herpes simplex keratitis (infection of
Blisters on the eyelid, sometimes with Usually only a doctor's
the cornea caused by the herpes
crusting examination
simplex virus)
Late or recurring: Eye redness and
watering, eye pain, impaired vision, and
sensitivity to light
Usually affecting only one eye
Herpes zoster ophthalmicus (shingles Early: A rash with blisters and/or crusts
Usually only a doctor's
that affects the face and eye, caused by on one side of the face, around the eye,
examination
the varicella-zoster virus) on the forehead, and sometimes on the
*Features include symptoms and the results of the doctor's examination. Features mentioned are typical
but not always present. Disorders usually affect only one eye unless otherwise specified.
†Doctors almost always do a slit-lamp examination with fluorescein staining and measure the pressure
inside the eye (called tonometry).
‡These causes are uncommon.
CT = computed tomography; MRI = magnetic resonance imaging.
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tip of the nose
Late: Eye redness, tearing, usually
sensitivity to light, and eyelid swelling
Usually affects both eyes
Symptoms that begin hours after
exposure to excessive ultraviolet light
(as is produced during arc welding, by a
Welder’s (ultraviolet) keratitis
sunlamp, or by bright sun reflecting off
(inflammation of the cornea caused by A doctor's examination
snow, particularly at high altitudes)
exposure to excessive ultraviolet light)
the eye
Eye redness, tearing, and sensitivity to
light
Other eye disorders
Severe eye ache and redness Tonometry†
Headache, nausea, vomiting, and pain Examination of the eye's
with exposure to light drainage channels with a
Closed-angle glaucoma
Disturbances in vision such as halos special lens (gonioscopy),
seen around lights and/or decreased done by an
vision ophthalmologist
Eye ache and sensitivity to light
Eye redness (particularly around the
Anterior uveitis (inflammation of the cornea)
anterior chamber—the fluid-filled space Blurring or loss of vision A doctor's examination
between the iris and cornea) Often in people who have an
autoimmune disorder or who recently
had an eye injury
Affecting only one eye
Eye ache, intense eye redness, A doctor's examination
Endophthalmitis (infection inside the sensitivity to light, and severely Cultures of fluids inside of
eye)‡ decreased vision the eye, done by an
Often in people who have had recent ophthalmologist
eye surgery or a serious eye injury
Usually mild pain that may worsen
Optic neuritis (inflammation of the A doctor's examination
when eyes are moved
optic nerve), which can be related to Often MRI with a
Partial or complete loss of vision
multiple sclerosis‡ radiopaque dye
Eyelids and corneas that appear normal
Affecting only one eye
Bulging of the eye, eye redness, pain
deep within the eye, and aches in and
around the eye
Red and swollen eyelids
Orbital cellulitis (infection of the tissue A doctor's examination
Inability to fully move the eye in all
within the eye socket, or orbit)‡ CT or MRI
directions
Impaired vision or loss of vision
Fever
Sometimes preceded by symptoms of
sinusitis (see below)
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Aches in and around the eye, which may
be very severe
Orbital pseudotumor (a noncancerous A doctor's examination
Often bulging of the eye
accumulation of inflammatory and CT or MRI
Often inability to fully move the eye in
fibrous tissue in the eye socket)‡ Sometimes biopsy
all directions
Swelling around the eye
Very severe pain, often described as
boring, and sensitivity to light
Watering of the eyes
Scleritis (inflammation of the white of Usually only a doctor's
Red or violet patches on the white of
the eye called the sclera) examination
the eye
Often in people who have an
autoimmune disorder
Other disorders that cause eye pain
In people who have had previous
episodes of severe headaches
Cluster headaches: Headaches that
Occur in clusters
Occur at the same time each day
Cause severe, piercing, knife-like

pain, a runny nose, and watery
eyes
Migraines: Headaches that

Cluster or migraine headaches Sometimes CT
May be preceded by temporary
disturbances in sensation,
balance, coordination, speech, or
vision (such as seeing flashing
lights or having blind spots),
called the aura
Typically cause a pulsating or

throbbing pain
Are accompanied by nausea,

vomiting, and sensitivity to
sounds, light, and odors
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Sometimes swelling around the eye but
no other eye symptoms
A yellow or green thick nasal discharge
(sometimes with bleeding), headache,
Sinusitis or eye or facial pain that varies with
Sometimes CT
head position
Fever, tenderness of the face,
sometimes a productive cough during
the night, and bad breath
Evaluation
Mild eye irritation or a foreign body sensation is common and not usually serious. However, true pain in the eye
can be a sign of a severe, vision-threatening disorder. The following information can help people decide when to
see a doctor and help them know what to expect during the evaluation.
Warning signs
In people with eye pain, certain symptoms and characteristics are cause for concern. They include
Vomiting
Halos around lights
Fever, chills, fatigue, or muscle aches
Decreased sharpness of vision (visual acuity)
Bulging of an eye (proptosis)
Inability to move the eye in all directions (such as right, left, up, and down)
When to see a doctor

People who have severe pain, eye redness, or warning signs should see a doctor right away. People with mild
pain and no eye redness or warning signs can wait a day or two to see if the discomfort goes away on its own.
What the doctor does

Doctors first ask questions about the person's symptoms and medical history. Doctors then do a physical
examination. What they find during the history and physical examination often suggests a cause of the eye pain
and the tests that may need to be done (see Table: Some Causes and Features of Eye Pain).
Doctors ask the person to describe the pain, including when it started, how severe it is, and whether it hurts to
look in different directions or blink. They ask about whether the person has ever had eye pain and whether the
person is sensitive to light, has blurred vision, or feels as if the eye contains a foreign object.
During the physical examination, doctors check for the presence of fever or a runny nose. They check the face for
tenderness.
Most important is the eye examination, including the entire eye, eyelids, and the region around the eye. Doctors
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check
Whether the eyes are red or swollen
How clearly a person can see using a standard eye chart (visual acuity)
Whether the person can see in each part of the field of vision (visual field testing)
How the pupils react to light
Whether shining a light into the unaffected eye causes pain in the affected eye when the affected eye is
closed (called true photophobia)
If doctors suspect a foreign object but do not see one, they turn the eyelids inside out to search for hidden
foreign objects.
Doctors usually do a slit-lamp examination. A slit lamp is an instrument that enables a doctor to examine the eye
under high magnification. Doctors place a drop of fluorescein stain on the cornea to show scratches or certain
kinds of infection, including ulcers. Doctors use tonometry to measure the pressure inside the eye (intraocular
pressure). They use an ophthalmoscope (a light with magnifying lenses that shines into the back of the eye) to
examine the lens, vitreous humor (the jellylike substance that fills the eyeball), retina (the light-sensing structure
at the back of the eye), optic nerve, and the retinal veins and arteries.
Sometimes findings are helpful in making a diagnosis. Particular findings or combinations may point to particular
disorders.
Findings may also help suggest or eliminate certain types of disorders.
Corneal disorders, among other disorders, tend to cause eye redness, tearing, and pain. If those symptoms
are absent, a corneal disorder is very unlikely.
Pain on the surface of the eye, a foreign body sensation, and pain with blinking suggest a foreign object.
People who wear contact lenses may have a corneal scratch, a corneal ulcer, or contact lens keratitis.
When measuring eye pressure, doctors put a drop of anesthetic into the eye. If pain then disappears, the
cause of pain is probably a corneal disorder.
Deep, aching, throbbing pain often indicates a possibly serious disorder such as acute closed-angle
glaucoma, anterior uveitis, scleritis, endophthalmitis, orbital cellulitis, or orbital pseudotumor. If, in
addition, there is eyelid swelling, bulging of the eye, or inability to move the eye to look in all directions, the
most likely disorders are orbital pseudotumor, orbital cellulitis, or possibly severe endophthalmitis.
Testing
The need for tests depends on what doctors find during the history and physical examination. Testing is usually
not necessary. However, if doctors find increased intraocular pressure, they may refer the person to an
ophthalmologist (a medical doctor who specializes in the evaluation and treatment—surgical and nonsurgical—of
eye disorders) for gonioscopy. A gonioscope is a special lens that allows doctors to examine the drainage
channels in the eye.
Bulging of the eye and inability of an eye to move in all directions without moving the head can indicate orbital
cellulitis or orbital pseudotumor. Computed tomography (CT) or magnetic resonance imaging (MRI) is then done
to check for these disorders. CT may also be done if sinusitis is suspected but the diagnosis is not otherwise clear
or if complications are suspected. MRI with a radiopaque dye may be done if optic neuritis is suspected.
Doctors send a sample of fluids from inside the eye (vitreous or aqueous humor) to the laboratory if
endophthalmitis seems likely. They may send a sample from the cornea or a blister if herpes simplex keratitis or
herpes zoster ophthalmicus seems likely but the diagnosis is not certain. In the laboratory, technicians try to grow
bacteria or viruses (culture) to confirm infections and determine the organism causing the infection.
Treatment
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Treatment of the cause
Pain relievers, sometimes opioids
Sometimes eye drops to dilate the pupil
The best way to treat eye pain is to treat the cause of the pain. People may also need to take pain relievers
(analgesics) until the pain stops. If an over-the-counter analgesic such as acetaminophen or a nonsteroidal anti-
inflammatory drug is ineffective, an opioid may be necessary. Sometimes people with pain caused by anterior
uveitis or corneal disorders also need to use an eye drop that prevents ciliary muscle spasm by dilating the pupil
and thus reduces eye pain with light exposure. For example, cyclopentolate may be used.
Key Points
Usually doctors can determine the cause of eye pain during an examination.
People with severe pain, eye redness, or warning signs (vomiting, halos around lights, fever,
decreased visual clarity, bulging eyes, and inability to move the eye in all directions) should see a
doctor right away.
Drugs Mentioned In This Article
Generic Name Select Brand Names
cyclopentolate AKPENTOLATE, CYCLOGYL
acetaminophen TYLENOL
Last full review/revision June 2018 by Christopher J. Brady, MD
© 2018 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA)
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Eye Pain - Eye Disorders - Merck Manuals Consumer Version https://www.merckmanuals.com/home/eye-disorders/symptoms-of...

An Inside Look at the Eye

However, most corneal disorders can cause eye pain.

Some Causes and Features of Eye Pain

Cause Common Features* Tests†

Cause Common Features* Tests†

Occur at the same time each day

Cause severe, piercing, knife-like

Migraines: Headaches that

Typically cause a pulsating or

Are accompanied by nausea,

Cause Common Features* Tests†

Halos around lights

Fever, chills, fatigue, or muscle aches

Decreased sharpness of vision (visual acuity)

Bulging of an eye (proptosis)

When to see a doctor

What the doctor does

How the pupils react to light

Treatment of the cause

Pain relievers, sometimes opioids

Sometimes eye drops to dilate the pupil

Drugs Mentioned In This Article

Generic Name Select Brand Names

cyclopentolate AKPENTOLATE, CYCLOGYL

Last full review/revision June 2018 by Christopher J. Brady, MD

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