What could be causing my 2-year history of eye pain, heaviness, and pressure in the head and face, particularly in the inner parts of my eyes, despite normal optic nerve evaluations by two different healthcare providers?

Evaluation of Chronic Eye Pain with Facial Pressure and Normal Optic Nerve Examination

You need urgent evaluation for neuropathic ocular pain (NOP), which occurs when the nerves supplying your eye surface become hyperexcitable and fire spontaneously, causing chronic burning, aching pain that far exceeds any visible signs of eye disease. 1

Understanding Your Symptoms

Your description of eye heaviness, pain with eye movement (especially looking up), inner eye pain, facial pressure, and head pressure—all persisting for 2 years despite normal optic nerve examinations—strongly suggests a neuropathic pain condition rather than a structural eye problem. 1

Key Diagnostic Features of Neuropathic Ocular Pain

The hallmark of NOP is symptoms that dramatically outweigh observable signs of disease. 1 Your case fits this pattern perfectly:

• Pain quality: Burning, stinging, or aching sensations are characteristic of nerve dysfunction 1
• Persistent symptoms: Pain continuing despite normal examinations suggests nerve hyperexcitability rather than tissue damage 1
• Associated features: Photophobia (light sensitivity) and wind sensitivity commonly accompany NOP 1

Critical Conditions to Rule Out First

Before confirming NOP, several serious conditions must be excluded given your symptom pattern:

Increased Intracranial Pressure

Despite two normal optic nerve examinations, increased intracranial pressure can occasionally present without papilledema initially. 2 Your constellation of symptoms—head pressure, facial pressure, and persistent eye pain—warrants:

• MRI brain with and without gadolinium contrast to evaluate for mass lesions, venous thrombosis, or signs of elevated pressure (empty sella, dilated optic nerve sheaths, posterior globe flattening) 2
• Fundoscopic re-examination specifically looking for subtle optic disc changes, venous engorgement, or hemorrhages 2

Cavernous Sinus or Orbital Pathology

Pain in the inner parts of your eyes with facial involvement suggests possible cavernous sinus or orbital disease. 1 These structures can cause:

• Facial pain through trigeminal nerve involvement 1
• Eye movement pain from inflammation affecting extraocular muscles or nerves 1
• Pressure sensations from venous congestion 1

Medication-Induced Angle Closure

If you take any medications containing sulfonamides (including topiramate for migraine or seizures), you could have intermittent angle closure causing your symptoms. 3 Topiramate can cause:

• Acute myopia with secondary angle closure glaucoma 3
• Ocular pain and pressure symptoms 3
• Symptoms typically within 1 month of starting but can occur later 3

Recommended Diagnostic Pathway

Immediate Steps (Within 1-2 Weeks)

1. Complete neuro-ophthalmologic examination including: 1, 2

   • Best-corrected visual acuity and color vision testing
   • Pupil examination for afferent defects or anisocoria
   • Intraocular pressure measurement
   • Gonioscopy to evaluate anterior chamber angle
   • Detailed fundoscopic examination for subtle papilledema

2. MRI brain with and without gadolinium contrast 2

   • Superior to CT for detecting structural lesions, demyelination, vascular abnormalities
   • Essential for visualizing optic nerve pathology and signs of increased intracranial pressure

3. Medication review 3

   • Specifically check for topiramate, sulfonamide antibiotics, or other medications causing angle closure
   • Review any anticholinergic or adrenergic medications

If Initial Workup is Normal: Neuropathic Ocular Pain Assessment

Once structural and secondary causes are excluded, perform the "anesthetic challenge test" to localize the pain source. 1 This test requires:

• Pain must be present before testing 1
• Instill topical anesthetic drops 1
• If pain improves: suggests peripheral neuropathic or nociceptive component 1
• If pain persists: suggests central nervous system or non-ocular pain source 1

Additional Evaluation for NOP

Assess for underlying triggers of nerve dysfunction: 1

• History of ocular surgery (refractive surgery, cataract extraction) 1
• History of ocular infections (especially herpes zoster) 1
• Chronic ocular surface disease (dry eye, inflammation) 1
• Associated conditions: migraine, fibromyalgia, traumatic brain injury 1

Use validated questionnaires: 1

• Neuropathic Pain Symptom Inventory (NPSI)-Eye 1
• Ocular Pain Assessment Survey (OPAS) 1

Treatment Approach for Neuropathic Ocular Pain

If NOP is confirmed, treatment depends on whether the nerve dysfunction is peripheral (corneal) or central: 1

For Peripheral NOP

• Topical nerve regenerative therapies 1
• Treatment of underlying ocular surface disease 1
• Autologous serum tears 1

For Central NOP

• Systemic neuropathic pain medications (gabapentin, pregabalin, tricyclic antidepressants) 1
• Referral to pain management specialist 1

Critical Pitfalls to Avoid

Do not dismiss your symptoms as "just stress" or "functional" without completing the full diagnostic workup. 1 The fact that two providers found normal optic nerves does NOT exclude:

• Neuropathic pain conditions 1
• Intermittent angle closure 3
• Early increased intracranial pressure 2
• Cavernous sinus pathology 1

Do not accept "your eyes are fine" as a final answer when you have life-altering symptoms for 2 years. 1 Demand referral to a neuro-ophthalmologist who specializes in complex eye pain and can perform the comprehensive evaluation outlined above. 1, 2

Urgent Referral Indications

Seek immediate evaluation if you develop: 2

• Sudden worsening of vision
• New double vision
• Pupil changes
• Severe sudden-onset headache
• Fever with your symptoms
• Scalp tenderness (if over age 50)