• Shruti GOCHHWAL

Why Do My Eyes Hurt? 9 Possible Reasons & When You Should See A Doctor

your eyes can hurt due to many reasons. There can be some underlying disease as well. You should get your eyes checked by an ophthalmologist. Find out the diseases that might cause your eyes to pain.

Patients with subtle abnormalities on exam

The first and most important step in the evaluation of eye pain is to perform a complete history and ocular exam. Most of the common etiologies for eye pain have obvious ocular exam findings (e.g., uveitis, corneal disease, dry eye, ophthalmoplegia). Subtle findings or footprints of prior etiologies can be easily missed by a cursory exam. The following etiologies require careful and specific evaluation in order to make the diagnosis.

Scleritis

Scleritis can present with ipsilateral eye pain. The pain is typically described as severe and deep, boring, and intense in quality. The pain may be intermittent or constant and is often associated with photophobia and tearing. Although typically centered on the eye or orbit pain, it may radiate to the face. There may be a history of underlying collagen vascular (e.g., systemic lupus erythematosus, rheumatoid arthritis) or inflammatory disease. Patients with anterior scleritis are easy to diagnose because of the obvious external signs (e.g., marked injection of the sclera, deep vessel engorgement, focal tenderness, scleral nodule or thinning).

Optic neuropathy

Pain may occur in patients with an optic neuropathy. In most cases the diagnosis of an optic neuropathy on clinical exam is made easily on the basis of these findings.

The optic disc is typically swollen in optic perineuritis, as opposed to a normal

optic nerve in retrobulbar optic neuritis. The response to corticosteroid therapy is generally more dramatic than for optic neuritis and recurrences may occur after therapy is stopped.

The pain in optic neuritis and optic perineuritis may precede the visual loss and the clinician should maintain a high index of suspicion for optic neuritis for young patients presenting with pain with eye movement. Pain may also be present in patients with ischemic optic neuropathy. Therefore, a complete exam of the afferent visual system (e.g., visual acuity, formal visual field, pupil testing) is necessary in all patients with eye pain. In addition, the patient should be cautioned to return if visual loss develops after the onset of eye pain.

Carotid cavernous fistula

Patients with carotid-cavernous sinus and dural-cavernous sinus fistulas typically have obvious orbital and lid findings. In these patients anterior drainage of the fistula into the superior ophthalmic vein produces the classic findings of the “red eye” shunt. However, some patients with low-flow dural-cavernous sinus fistulas predominantly present with eye pain with or without motility impairment but without significant eye redness or edema.

Herpes zoster ophthalmicus

Herpes zoster virus involving the trigeminal nerve can produce eye pain. Typically, there is evidence of the active or past vesicular, dermatomal distribution cutaneous eruption. Ocular involvement (e.g., scleritis, uveitis, keratitis) can occur after ophthalmic zoster. A history of zoster ophthalmicus or evidence for the vesicular rash should be sought in patients with presumed post herpetic neuralgia.

Patients with transient abnormality on the ocular exam

Patients with intermittent symptoms of eye pain may have a normal exam at the time of the ophthalmologic visit. In these patients, a careful exam for the “footprints” of a prior etiology should be performed. In addition, patients with recurrent symptoms might be asked to try to come in to the office during pain symptoms rather than simply scheduling a regular appointment. Several conditions present with intermittent symptoms and signs that are detectable only during an attack.

Dry eye

Patients with dry eye may complain of recurrent, intermit- tent, or constant unilateral or bilateral eye pain. Patients with severe dry eye often demonstrate obvious tear film abnor- malities, corneal epithelial erosions, epithelial staining with topical dyes (e.g., rose bengal, fluorescein) and abnormal Schirmer testing. Milder cases of dry eye however may have only intermittent or subtle signs. Clinicians should however avoid the temptation to provide topical anesthetic to eye pain patients as a treatment since chronic use of topical anesthetics may lead to masking of symptoms, abuse of the drug, and corneal toxicity.

Orbital disease

Patients with orbital disease (e.g., infection, tumor, inflammation, vascular lesions) typically produce obvious orbital signs, including proptosis, chemosis, injection, or ophthalmoplegia. Intermittent orbital pain with or without proptosis may occur with orbital vascular lesions (e.g., venous or arteriovenous malformations or lymphangioma). In these patients symptoms may occur transiently with straining (e.g., Valsalva maneuver), coughing, crying, bending, or hyperextending the neck. During the attacks the eye may become tense and painful, the pupil may dilate, and occasionally bradycardia or syncope may develop (oculocardiac syndrome). Gaze-evoked amaurosis (loss of vision in certain gaze positions) is also a sign of an orbital process. In specific positions of gaze the orbital lesion presumably compresses the optic nerve or the vascular supply and produces transient visual loss. Patients can be examined or imaged during the precipitating circumstance (e.g., Valsalva or head- hanging maneuver) in order to make the diagnosis.

Phantom eye pain

Patients who have undergone enucleation can develop phantom eye pain or phantom non-painful visual phenome- non (e.g., photopsias). Some patients with persistent pain after enucleation have an underlying amputation neuroma as the etiology. Clinicians should recognize that pain can persist in the eye even after enucleation.

Idiopathic orbital myositis

As noted above, although most patients with orbital inflammatory pseudotumor have definite abnormalities on the ocular exam (e.g., proptosis, ophthalmoplegia, red eye, some have a normal ocular exam. This is especially true for one subtype of orbital inflammatory disease, orbital myositis. Myositis is typically milder in severity, has a predilection for middle-aged adults, and is more common in women (2 : 1). The distinctive symptom is orbital pain wors- ened with eye movement. Superimposed or concomitant thyroid ophthalmopathy may occur in these patients.

Cluster headache may be mimicked (“secondary” cluster) by sphenoid wing or high cervical meningioma, pituitary adenoma, dissection or aneurysm of the vertebral artery, occipital arteriovenous malformation, pseudoaneurysm of the intracavernous carotid artery, trauma, orbital/sphenoidal aspergillosis, temporal arteritis, and the Tolosa-Hunt syndrome. Atypical cases of cluster may be due to underlying orbital myositis.

Primary short-lasting eye pain syndromes without autonomic features

The primary short lasting eye pain syndromes without autonomic features include: trigeminal neuralgia, sphenopalatine and vidian neuralgia, ice-pick headache, exertional or cough related headache, and ice cream headache.

Trigeminal neuralgia

Trigeminal neuralgia (tic douloureux) is characterized by acute, severe, excruciating, lancinating, paroxysmal, and unilateral pain in the distribution of one or more of the divisions (often the maxillary or mandibular) of the trigeminal nerve. Ophthalmic division involvement is uncommon but can cause or be associated with stabbing eye pain. It is more common with older age, affects women more than men, and affects the right side more than the left. It is rarely bilateral (except in multiple sclerosis). The paroxysms are brief, usually lasting less than a minute. In severe cases, the pain may occur several times a day. The attacks are most frequent during the day, but may awaken the patient at night. The painful paroxysms are often triggered by non-nociceptive facial stimulation (e.g., touch, jaw movement, drinking hot or cold liquids).

Greater occipital neuralgia

Greater occipital neuralgia is a pain syndrome that is presumed to be due to irritation of the greater occipital nerve. The pain begins in the occiput but can radiate anteriorly to the ipsilateral eye. Local injection of the nerve with anesthetic may relieve the pain.

Exertional or cough related headache or eye pain

Although cough or exertional headache/eye pain may occur in patients due to transient increased intracranial pressure, most patients have negative neuroimaging. In these patients the pain with exertion, cough, or sexual activity is benign. The duration of episodes is short (less than one minute, but occasionally 30 minutes). Post-coital headache or orgasmic headache is typically frontal or occipital in location. The pain is often severe, explosive or throbbing in quality, and persists for minutes to hours.

Ice-cream headache

Eating ice cream or rapidly drinking a cold drink may cause severe pain (cold stimulus or ice-cream headache). The pain typically lasts 25 to 60 seconds and may be referred to the eye. The location may be unilateral or bifrontal and is more common in patients with migraine.

Migraine headache

Migraine is a common headache syndrome. Women are more affected than men. The headache duration is typically 4 to 72 hours. Migraine is usually unilateral and hemicranial (but can be bilateral or diffuse). The pain is typically described as pulsating or throbbing in quality and of moderate to severe intensity. Many patients have to stop what they are doing and the pain is often aggravated by routine physical activity. Pain referred to the eye is uncommon with typical migraine but can occur. Isolated eye pain, however, is unusual with migraine.

Tension headache

Tension headache is another common headache syndrome that may have an associated eye pain component. The headache is described as a “pressure” or “tightening” band and may be of mild or moderate severity. It is often bilateral and frontal. Autonomic dysfunction (e.g., nausea and vomiting) is typically absent. Refractive error, anisometropia, heterophoria or heterotropia, or prolonged or “intense” reading or studying may play a role in exacerbating or precipitating tension headache.

Paranasal sinus disease

Paranasal sinus disease can refer to the ipsilateral face or eye. Frontal sinus disease produces pain that is localized over the brow and forehead but may radiate to the eye or orbit. The pain is typically dull, deep, and aching in quality. Tenderness over the involved sinus may occur. Many patients report a long-standing history of sinus disease, sinus drainage, or other sinus symptoms.

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