What could be causing my orbital pain and pain when moving my eye, and how should it be treated?

Orbital Pain with Eye Movement: Differential Diagnosis and Management

Orbital pain exacerbated by eye movement most commonly indicates orbital myositis, orbital cellulitis, or optic neuritis, and requires urgent ophthalmologic evaluation to rule out vision-threatening conditions.

Immediate Assessment Required

You must perform a focused examination to identify vision-threatening emergencies before pursuing definitive diagnosis:

• Check visual acuity immediately to detect any vision loss 1
• Perform pupillary examination looking for afferent pupillary defect or signs of increased intraocular pressure 2
• Measure intraocular pressure to exclude acute angle-closure glaucoma 2, 3
• Assess extraocular motility noting any restriction or pain with specific movements 1, 4
• Examine for proptosis using exophthalmometry if available 1, 2
• Look for periorbital edema, conjunctival injection, or chemosis which help narrow the differential 4, 5

Critical Red Flags Requiring Emergency Ophthalmology Consultation

Refer immediately if any of these are present 3:

• Vision loss or significant vision changes
• Severe pain with bradycardia, nausea, or vomiting (suggests oculocardiac reflex from muscle entrapment) 1, 2
• Signs of orbital cellulitis: fever, severe periorbital swelling, restricted eye movements 3, 6
• Pupillary abnormalities suggesting optic nerve involvement 3
• Acute angle-closure glaucoma: rock-hard eye, mid-dilated pupil, severe pain 3

Most Likely Diagnoses Based on Clinical Pattern

Orbital Myositis (Most Common in Young Adults)

This is the leading diagnosis when pain with eye movement is the cardinal feature 4, 5:

• Typically affects young to middle-aged adults with 2:1 female predominance 4, 5
• Acute onset of severe orbital pain that worsens dramatically with eye movement 5
• Usually unilateral initially, though chronic cases can be bilateral 4
• Associated with diplopia, minimal proptosis, conjunctival injection 4, 5
• Responds rapidly to systemic corticosteroids, which helps distinguish it from thyroid eye disease 4, 5

Orbital Cellulitis

Consider this if there are systemic signs of infection 3, 6:

• Pain with eye movement plus fever, periorbital swelling, restricted motility 6
• May develop from ethmoidal sinusitis 6
• Can progress to superior ophthalmic vein thrombosis 6
• Requires immediate broad-spectrum IV antibiotics and imaging 6

Optic Neuritis

Suspect if vision loss accompanies the pain 3:

• Pain with eye movement is classic, often preceding vision loss
• Afferent pupillary defect typically present
• Requires urgent ophthalmology referral 3

Imaging Strategy

Order CT orbit without contrast with thin cuts and multiplanar reconstructions as first-line imaging 1, 2:

• CT has 94.9% sensitivity for detecting orbital pathology and foreign bodies 1, 7
• Do not order MRI if any possibility of metallic foreign body 1, 8
• MRI is superior for soft tissue detail of extraocular muscles if myositis is suspected and metallic foreign body excluded 1
• Orbital myositis shows enlarged muscle bellies with thickened tendons on CT 5

Treatment Algorithm

If Orbital Myositis is Confirmed:

• Start systemic corticosteroids (typically prednisone 1 mg/kg/day) 4, 5
• Expect rapid improvement within days 4, 5
• For chronic or recurrent cases, consider steroid-sparing immunosuppressants or radiation therapy 4

If Orbital Cellulitis is Diagnosed:

• Immediate IV broad-spectrum antibiotics 6
• Consider anticoagulation if superior ophthalmic vein thrombosis develops 6
• Monitor closely for progression to cavernous sinus thrombosis

If Optic Neuritis:

• Urgent ophthalmology and neurology consultation 3
• High-dose IV corticosteroids typically indicated

Common Pitfalls to Avoid

• Do not dismiss pain with eye movement as simple conjunctivitis or eye strain - this symptom pattern demands investigation for serious pathology 3, 9
• Do not confuse orbital myositis with thyroid eye disease - myositis has more acute onset, more severe pain, and rapid steroid response 4, 5
• Do not delay imaging in suspected orbital cellulitis - progression can be rapid and vision-threatening 6
• Do not order MRI before excluding metallic foreign body if any trauma history 1