What are the causes and treatments of eye pain that occurs with movement?

Eye Pain with Movement: Causes and Differential Diagnosis

Eye pain with movement is most commonly caused by optic neuritis in neurologic settings, but inflammatory ocular surface disease (conjunctivitis, keratitis, blepharitis, dry eye) accounts for the majority of cases overall, and serious vision-threatening conditions like acute angle-closure glaucoma must be urgently excluded. 1

Algorithmic Approach to Diagnosis

Step 1: Identify Red Flags Requiring Emergency Referral

Immediately refer to ophthalmology if any of the following are present:

• Acute vision loss or significant vision changes - suggests optic neuritis, acute angle-closure glaucoma, or orbital cellulitis 2
• Severe headache with eye pain - consider acute angle-closure glaucoma or giant cell arteritis 2
• Proptosis or restricted eye movements - indicates orbital cellulitis or other orbital pathology 2
• Pupillary abnormalities (especially mid-dilated, non-reactive pupil) - suggests acute angle-closure glaucoma 2
• Corneal opacity or haze - indicates infectious keratitis or severe inflammation 2

Step 2: Determine Pain Pattern and Associated Symptoms

Pain specifically with eye movement suggests:

• Optic neuritis - the classic presentation, often with vision loss and afferent pupillary defect 1
• Scleritis - deep, boring pain that worsens with eye movement 2
• Orbital inflammation or myositis - pain with specific directions of gaze 3

Pain without specific movement trigger suggests:

• Inflammatory ocular surface disease (69% of all eye pain cases) - includes conjunctivitis, keratitis, blepharitis, dry eye, chalazion, uveitis 1
• Neuropathic ocular pain - burning, stinging, or aching quality with photophobia and symptoms exceeding clinical signs 4
• Migraine (51% of eye pain in neurology clinics) - associated with headache, photophobia 1

Step 3: Perform Targeted Physical Examination

Visual acuity testing - any decrease warrants urgent ophthalmology referral 2

Pupillary examination - check for:

• Afferent pupillary defect (optic neuritis) 2
• Mid-dilated non-reactive pupil (acute angle-closure glaucoma) 2

External examination - assess for:

• Conjunctival injection pattern (diffuse vs. circumcorneal) 2
• Eyelid abnormalities (chalazion, blepharitis) 1
• Proptosis or periorbital edema (orbital cellulitis) 2

Extraocular movements - pain with specific movements localizes to optic nerve or orbital structures 5

Fluorescein staining - identifies corneal abrasions, epithelial defects, or keratitis 2

Tonometry - elevated intraocular pressure (>21 mmHg) suggests angle-closure glaucoma 2

Common Causes by Clinical Setting

In Ophthalmology Clinics (92% of cases):

• Inflammatory eye disease: 69% - conjunctivitis, keratitis, blepharitis, dry eye, chalazion, scleritis 1
• Corneal abrasion and trauma 2
• Acute angle-closure glaucoma 2
• Migraine: only 3% in ophthalmology settings 1

In Neurology Clinics:

• Migraine: 51% of eye pain presentations 1
• Optic neuritis: 22% (44 of 196 patients) 1
• Trigeminal neuralgia and cranial nerve disorders 1

Special Consideration: Neuropathic Ocular Pain

Suspect neuropathic ocular pain when:

• Symptoms significantly outweigh clinical signs 4
• Pain persists despite appropriate treatment of ocular surface abnormalities 4
• Pain described as burning, stinging, aching with photophobia and wind sensitivity 4
• History of prior ocular surgery, infection (herpes zoster), or chronic dry eye 4

Diagnostic anesthetic challenge test:

• Instill topical anesthetic when pain is present 4
• Pain improvement suggests peripheral neuropathic or nociceptive component 4
• Persistent pain suggests central or non-ocular cause 4

Treatment approach for neuropathic ocular pain:

• Peripheral component: autologous serum tears 4
• Central component: oral neuromodulators (pregabalin, gabapentin, duloxetine, amitriptyline, nortriptyline, low-dose naltrexone) 4
• With photophobia/headache: transcutaneous electrical nerve stimulation or periorbital botulinum toxin A 4
• Postsurgical/allodynia: periocular nerve blocks with corticosteroid and long-acting sodium channel blocker 4
• Critical expectation setting: neuromodulators require 3-4 months at therapeutic dose to show effect 4
• Multidisciplinary approach: involve ophthalmology, pain specialists, neurology, and mental health professionals given high rates of comorbid anxiety and depression 4

Critical Pitfalls to Avoid

Do not dismiss pain with minimal findings - neuropathic ocular pain and early optic neuritis can present with "quiet" eyes 4, 3

Do not delay referral for vision-threatening conditions - acute angle-closure glaucoma, optic neuritis, orbital cellulitis, scleritis, anterior uveitis, and infectious keratitis all require urgent ophthalmology consultation 2

Do not attribute all eye pain to dry eye - this misses serious neurologic and inflammatory conditions 1, 3

Do not overlook medication-induced causes - topiramate can cause acute myopia with secondary angle-closure glaucoma, presenting as acute eye pain with vision changes within 1 month of initiation 6