What could be causing pain behind the eye with eye movement and how should it be treated?

Pain Behind Eye with Eye Movement: Diagnostic and Treatment Approach

Primary Diagnosis to Exclude First

Optic neuritis is the most critical diagnosis to rule out when a patient presents with pain behind the eye that worsens with eye movement, as this represents a potentially vision-threatening inflammatory condition requiring urgent evaluation and treatment. 1

Pain with eye movement is a classic hallmark of optic neuritis, which typically presents with subacute unilateral visual impairment accompanied by pain on eye movement. 1 This specific symptom pattern—pain exacerbated by ocular motility—strongly suggests inflammation of the optic nerve rather than other ocular surface or neuropathic conditions.

Immediate Diagnostic Evaluation Required

Critical History Elements

• Visual changes: Assess for blurred vision, color desaturation, or visual field defects that accompany the pain 1
• Timing: Optic neuritis develops subacutely over hours to days 1
• Pain characteristics: Pain behind or around the eye that worsens specifically with eye movements 1
• Systemic symptoms: Prior neurologic episodes suggesting demyelinating disease 1

Essential Physical Examination

• Visual acuity testing: Document baseline vision, as optic neuritis causes measurable visual impairment 1
• Pupil examination: Look for relative afferent pupillary defect (Marcus Gunn pupil), which is present in most cases of optic neuritis 2
• Slit-lamp biomicroscopy: Rule out anterior segment inflammation 2
• Fundoscopy: Examine optic disc for swelling, though optic neuritis may present with normal-appearing disc in retrobulbar cases 1

Differential Diagnosis Framework

If Visual Impairment Present with Pain on Movement

Optic neuritis is the primary diagnosis until proven otherwise. 1 Proceed immediately with:

• Brain MRI with and without contrast to evaluate for demyelinating lesions 1
• Ophthalmology consultation for comprehensive neuro-ophthalmic evaluation 3

If No Visual Impairment but Pain Persists

Consider secondary diagnoses:

Posterior scleritis presents with deep pain and painful eye movements, but typically shows:

• Hyperemia of conjunctiva and large scleral vessels 2
• Fluid in sub-Tenon space (T-sign) on ultrasonography 2
• No leakage on fluorescein angiography 2

Orbital inflammatory conditions may cause pain with eye movement due to extraocular muscle involvement:

• MRI of orbits with and without contrast is optimal for localizing and characterizing orbital lesions 2
• Look for proptosis, orbital congestion, or restricted eye movements 2

Neuropathic ocular pain should be suspected when symptoms significantly outweigh clinical signs, but this diagnosis requires:

• Normal or minimal ocular surface findings 4, 5
• Pain described as burning, stinging, or aching rather than sharp pain with movement 4
• Diagnostic anesthetic challenge test showing no improvement (suggesting central cause) 4, 5

Treatment Algorithm

For Confirmed Optic Neuritis

Intravenous methylprednisolone is the standard acute treatment, which hastens visual recovery but does not alter ultimate visual outcome. 1

• Brain MRI findings compatible with multiple sclerosis warrant introduction of disease-modifying therapy after even a single clinical event like optic neuritis 1
• Provide detailed explanation of potential MS diagnosis and connect patient with support services 1
• Most cases resolve spontaneously, but treatment accelerates recovery 1

For Posterior Scleritis

• Systemic corticosteroids are first-line treatment 2
• Other systemic immunosuppressive medications may be required 2

For Neuropathic Ocular Pain (if diagnosed)

• Peripheral component: Autologous serum tears 4, 5
• Central component: Oral neuromodulators (pregabalin, gabapentin, duloxetine, amitriptyline, nortriptyline, low-dose naltrexone) 4, 5
• Photophobia/headache: Transcutaneous electrical nerve stimulation or periorbital botulinum toxin A 4, 5
• Multidisciplinary approach with pain specialists, neurology, and mental health professionals due to high comorbid anxiety and depression 4

Critical Pitfalls to Avoid

Do not dismiss pain with eye movement as benign dry eye or neuropathic pain without first excluding optic neuritis. 1 The combination of pain specifically worsened by eye movement plus any degree of visual impairment is optic neuritis until proven otherwise.

Do not delay neuroimaging in patients with isolated eye pain and movement-related pain. 6 While neuroimaging is often normal in chronic isolated eye pain, delayed diagnosis of neuro-ophthalmic causes could result in significant morbidity. 6

Recognize that inflammatory eye diseases (conjunctivitis, blepharitis, keratitis) account for 69% of eye pain presentations to ophthalmology clinics, but these conditions do not typically cause pain specifically with eye movement. 7 Pain with movement suggests deeper orbital or optic nerve pathology.