From the Guidelines
The workup for painful eye movements should begin with a comprehensive history and physical examination, focusing on the onset, duration, and characteristics of the pain, as well as associated symptoms like vision changes or headaches, as recommended by the most recent study 1. A complete ocular examination including visual acuity testing, pupillary responses, extraocular movement assessment, and fundoscopic examination is essential.
- The examination should include vision testing, refraction, pupillary examination, IOP measurement, confrontational visual field testing, slit-lamp examination, and a dilated or undilated fundus examination, as outlined in the adult strabismus preferred practice pattern 1.
- A detailed sensorimotor examination should be performed, with attention to versions, ductions, saccades, pursuit, vergence, and near reflex, along with alignment in multiple gaze positions with attention to primary and secondary deviations. Neurological examination should evaluate cranial nerves, particularly II, III, IV, and VI.
- Laboratory tests may include complete blood count, erythrocyte sedimentation rate, C-reactive protein, and specific tests for suspected conditions like thyroid function tests for Graves' disease. Imaging studies are crucial, with MRI of the brain and orbits being the preferred modality to evaluate for demyelinating diseases (like multiple sclerosis), orbital inflammation, or mass lesions, as suggested by the American College of Radiology 1.
- CT scans may be useful for evaluating bony structures and sinuses, and can provide complementary information to MRI in certain cases. In cases suggesting optic neuritis, visual evoked potentials can be helpful.
- Lumbar puncture may be indicated if multiple sclerosis or infectious causes are suspected, as part of a comprehensive diagnostic approach. This comprehensive approach is necessary because painful eye movements can result from various conditions including optic neuritis, orbital inflammatory disease, thyroid eye disease, orbital cellulitis, or cranial nerve palsies, each requiring different management strategies, as highlighted in the study on neuropathic corneal pain 1.
From the Research
Workup for Painful Eye Movements
The workup for painful eye movements involves a comprehensive evaluation of the patient's symptoms and medical history.
- A thorough ocular examination is necessary, including:
- Visual acuity testing
- Pupil examination
- External examination
- Extraocular movements
- Visual fields
- Color vision
- The patient should then be examined at the slit lamp, followed by an examination of the fundus and optic nerve with a direct ophthalmoscope and measurement of intraocular pressure 2
- Special tests such as plain film studies and computed tomography (CT) scans may be obtained when indicated
- Referral to an ophthalmologist may be necessary for a dilated fundus examination, ultrasound studies of the eye and orbit, and surgical treatment 2
Diagnostic Considerations
In cases of optic neuritis, which can cause painful eye movements, the following diagnostic considerations are important:
- Gadolinium-enhanced MRI of the brain and orbits to determine the risk of developing multiple sclerosis 3
- Evaluation of visual acuity, visual fields, and color vision
- Examination of the optic nerve and retina
Treatment Options
Treatment options for painful eye movements depend on the underlying cause.
- For optic neuritis, treatment with intravenous methylprednisolone followed by oral prednisone may be effective in hastening visual recovery 3
- Bioequivalent doses of oral corticosteroids may be used as an alternative to intravenous corticosteroids 4
- In some cases, interferon beta 1-a may be considered to reduce the risk of developing multiple sclerosis 3