How do you document pain associated with Extraocular Movement (EOM) in a patient?

Documenting Pain with Extraocular Movement (EOM)

Document pain with extraocular movement by recording the presence or absence of pain during testing of all six cardinal directions of gaze, noting the specific direction(s) that elicit pain, the severity using a standardized pain scale (0-10 numeric rating scale), and associated findings such as restriction of movement, diplopia, or periorbital swelling. 1

Essential Documentation Components

Pain Assessment During EOM Testing

• Test all six cardinal directions of gaze (up, down, left, right, up-right, up-left, down-right, down-left) and document which specific movements elicit pain 2, 3, 4

• Use a standardized pain scale such as the 0-10 Numerical Rating Scale (NRS) or Visual Analog Scale (VAS) to quantify pain severity during movement 5, 1

• Ask the key screening question: "What is your pain level during eye movement on a scale of 0-10, where 0 is no pain and 10 is the worst imaginable?" 5

Specific Clinical Descriptors to Document

• Pain quality: Record whether the pain is sharp, aching, burning, or stabbing during movement 5

• Pain location: Document if pain is retro-orbital, periorbital, or diffuse 2, 3

• Temporal pattern: Note if pain occurs with all movements or only specific directions 2, 4, 6

• Associated symptoms: Record presence of diplopia, proptosis, eyelid swelling, conjunctival injection, chemosis, or photophobia 2, 3, 4, 6

Physical Examination Findings

• Movement restriction: Document any limitation in range of motion in specific directions 2, 4, 6

• Periorbital findings: Note eyelid edema, erythema, or soft tissue swelling 3, 4

• Conjunctival examination: Record injection, chemosis, or hyperemia 2, 6

• Pupillary response and visual acuity: Document any abnormalities that may indicate serious pathology 3

Documentation Format Example

A practical documentation format should include:

• "Pain with EOM: Present/Absent"
• "Severity: [X]/10 on NRS during [specific direction] movement" 5, 1
• "Worst pain: [X]/10 during [direction]" 5
• "Associated findings: [restriction/diplopia/swelling/none]" 2, 3, 4

Critical Clinical Context

When Pain with EOM Suggests Serious Pathology

• Orbital cellulitis: Pain with EOM accompanied by periorbital edema, proptosis, and fever requires immediate imaging and treatment 2, 3

• Orbital myositis: Acute onset of pain with EOM, restriction of movement, and periorbital swelling suggests inflammatory process requiring corticosteroid therapy 4, 6

• Optic perineuritis: Progressive pain with EOM combined with declining visual acuity and dyschromatopsia requires urgent MRI and lumbar puncture 3

Reassessment Requirements

• Re-document pain severity at 48-72 hours after initiating treatment to confirm clinical improvement 1

• Pain should improve within 72 hours of appropriate therapy; lack of improvement warrants reassessment for alternative diagnoses 1

• Document pain at rest versus with movement to differentiate nociceptive from neuropathic components 5

Common Documentation Pitfalls

• Failing to quantify pain severity using a standardized scale makes it impossible to track treatment response objectively 5

• Not documenting specific directions of gaze that elicit pain can delay diagnosis of conditions like orbital myositis where specific muscle involvement is diagnostic 4, 6

• Omitting associated symptoms such as diplopia or visual changes may miss serious conditions requiring urgent intervention 3