Eye pain/discomfort

Medicine > Neurosciences

Differential Diagnosis Schema 🧠

Ocular Causes

Corneal abrasion: Sharp, localized pain, often following trauma or foreign body exposure
Conjunctivitis: Gritty or burning sensation, often with discharge and redness
Acute angle-closure glaucoma: Severe, sudden eye pain with blurred vision, halos around lights, and nausea
Uveitis: Deep, aching pain with photophobia and blurred vision; often associated with systemic inflammatory conditions
Scleritis: Severe, boring eye pain, often associated with systemic autoimmune diseases
Keratitis: Pain, photophobia, and possible corneal ulceration; commonly associated with contact lens use or viral infections
Optic neuritis: Pain with eye movement, often with visual loss and color desaturation; associated with multiple sclerosis
Foreign body: Sensation of something in the eye, with associated irritation and tearing
Dry eye syndrome: Gritty, burning sensation, often worse at the end of the day or after prolonged visual tasks
Blepharitis: Burning, irritation, and crusting around the eyelids, often associated with meibomian gland dysfunction

Non-Ocular Causes

Sinusitis: Dull, aching pain around the eyes, often associated with nasal congestion and tenderness over the sinuses
Migraine: Unilateral, throbbing pain, often with associated visual aura, photophobia, and nausea
Cluster headache: Severe, unilateral pain around the eye, often accompanied by lacrimation, rhinorrhea, and ptosis
Temporal arteritis: Unilateral or bilateral deep, aching pain with scalp tenderness, jaw claudication, and systemic symptoms such as fatigue
Trigeminal neuralgia: Sharp, stabbing pain in the distribution of the trigeminal nerve, which may involve the eye area
Referred pain: Pain originating from dental, temporomandibular joint (TMJ), or cervical spine issues can be perceived as eye pain
Herpes zoster ophthalmicus: Pain, photophobia, and vesicular rash in the distribution of the trigeminal nerve, typically involving the forehead and eye
Carotid artery dissection: Sudden-onset eye pain with associated headache and possible Horner’s syndrome (ptosis, miosis, anhidrosis)

Key Points in History 🥼

Symptom Characteristics

Onset and duration: Sudden-onset pain may suggest acute conditions like glaucoma or optic neuritis, while gradual onset may indicate chronic issues like dry eye
Location: Unilateral pain may point to a localized issue, while bilateral pain may suggest systemic causes
Nature of pain: Sharp or stabbing pain is often associated with corneal abrasion or foreign body, while dull or aching pain may be related to uveitis or sinusitis
Associated visual changes: Blurred vision, halos, or photophobia can help differentiate between various causes
Photophobia: Sensitivity to light may indicate uveitis, keratitis, or acute glaucoma
Discharge: Watery discharge is common in viral conjunctivitis, while purulent discharge suggests bacterial infection
Systemic symptoms: Fever, malaise, or recent illness can point towards infections like herpes zoster or sinusitis
Previous eye conditions: History of similar episodes, contact lens use, or previous eye trauma can provide diagnostic clues

Background

Past medical history: Previous episodes of uveitis, glaucoma, or sinusitis, as well as systemic conditions like autoimmune diseases
Medication history: Use of topical or systemic medications, including steroids or anticoagulants
Family history: Consider hereditary conditions such as glaucoma or migraine
Social history: Contact lens use, occupational exposures, and recent travel
Drug history: Use of recreational drugs, especially those that could cause vasoconstriction or dry eyes
Allergies: History of allergic rhinitis or atopic conditions that may predispose to allergic conjunctivitis
Surgical history: Previous eye surgeries or procedures

Possible Investigations 🌡️

Laboratory Tests

Full blood count: To assess for infection or inflammation
Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP): Elevated in conditions like temporal arteritis
Autoimmune screen: ANA, RF, and other tests if an autoimmune cause is suspected (e.g., uveitis, scleritis)
Viral swabs or serology: For suspected viral infections like herpes simplex or varicella-zoster
Blood glucose levels: Important in diabetic patients presenting with optic neuritis or retinopathy
Thyroid function tests: If thyroid eye disease is suspected
Culture and sensitivity: For any discharge present, especially if bacterial infection is suspected

Imaging and Specialist Tests

Slit-lamp examination: Essential for diagnosing conditions like uveitis, keratitis, and corneal abrasions
Tonometry: To measure intraocular pressure, crucial in diagnosing acute angle-closure glaucoma
Ophthalmoscopy: To assess the retina and optic nerve, particularly in optic neuritis or retinal detachment
CT or MRI of the orbits: Indicated in cases of suspected orbital cellulitis, optic neuritis, or sinusitis with orbital involvement
Temporal artery biopsy: If temporal arteritis is suspected based on clinical findings and elevated ESR/CRP
Fluorescein staining: To identify corneal abrasions, ulcers, or foreign bodies
Visual field testing: To assess for defects associated with glaucoma, optic neuritis, or other neuro-ophthalmic conditions

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