Painful eyes with normal exam

Background

Eye anatomy.

• Eye pain with an unremarkable external exam and normal slit-lamp findings poses a diagnostic challenge
• Key concern: must rule out sight- and life-threatening conditions that may not show early external signs
• High-risk diagnoses to consider: optic neuritis, temporal arteritis, acute angle closure glaucoma (early), posterior scleritis, ocular ischemic syndrome

Clinical Features

• Normal external eye exam (no injection, no discharge, no corneal findings)
• Patient reports significant eye pain, periorbital pain, or retrobulbar pain
• May have associated symptoms guiding diagnosis (see below)

Differential Diagnosis

Ocular/Orbital

• Optic neuritis — pain with eye movement, decreased visual acuity, afferent pupillary defect
• Posterior scleritis — deep aching pain, may have decreased VA; scleral thickening on B-scan US
• Acute angle closure glaucoma (early) — elevated IOP may be only finding before conjunctival injection develops
• Ocular ischemic syndrome — dull ache, carotid disease, may have low IOP

Referred Pain

• Sinusitis — frontal/maxillary tenderness, nasal congestion, worse with bending
• Temporal arteritis — age >50, scalp tenderness, jaw claudication, elevated ESR/CRP
• Migraine or cluster headache — headache history, associated aura or autonomic symptoms
• Trigeminal neuralgia — lancinating pain in V1 distribution
• Shingles (herpes zoster ophthalmicus) — may precede rash by days (prodromal pain)

Systemic

• Diabetic cranial neuropathy (CN III, IV, or VI)

Evaluation

• Complete eye exam: visual acuity, pupil exam (APD?), IOP, slit-lamp, dilated fundoscopy
• IOP measurement — critical to rule out early angle closure
• ESR and CRP if age >50 or concern for temporal arteritis
• Consider CT/MRI orbits if orbital or retrobulbar process suspected
• MRI brain/orbits with contrast if optic neuritis suspected

Management

• Treat underlying condition
• If no diagnosis after thorough workup: ophthalmology follow-up within 24-48 hours

Disposition

• Urgent ophthalmology referral for decreased visual acuity, elevated IOP, or APD
• Emergent workup for suspected temporal arteritis (ESR/CRP, start empiric steroids pending biopsy)

See Also

Eye Algorithms

• Red eye
  • Bilateral red eyes
  • Unilateral red eye
  • Red eye (by symptoms)
  • Red eye (peds)
    • Neonatal conjunctivitis
• Periorbital swelling
• Acute vision loss (noninflamed)
• Acute onset flashers and floaters
• Painful eyes with normal exam
• Neonatal eye problems