What is the cause of persistent pain above the left eye, and how should it be managed?

Pain Above Left Eye: Diagnostic and Management Approach

Pain above the left eye requires systematic evaluation to distinguish between benign conditions like tension-type headache or sinusitis from serious pathology including optic neuritis, orbital inflammation, or neuropathic ocular pain, with the diagnostic approach guided by associated symptoms and examination findings. 1, 2

Initial Diagnostic Evaluation

Critical Red Flags Requiring Urgent Ophthalmology Consultation

• Vision loss or changes - suggests optic neuritis, ischemic optic neuropathy, or acute angle-closure glaucoma 1, 3
• Pain worsening with eye movement - highly suggestive of optic neuritis or posterior scleritis 1
• Relative afferent pupillary defect (Marcus Gunn pupil) - present in most cases of optic neuritis 1
• Diplopia or ophthalmoplegia - indicates orbital inflammatory disease, cranial nerve involvement, or Tolosa-Hunt syndrome 4, 5
• Severe headache in patients >50 years - must rule out giant cell arteritis, which can mimic temporomandibular disorders 6

Key History Elements

• Character of pain: Burning, stinging, or aching suggests neuropathic ocular pain; electric shock-like pain provoked by light touch indicates trigeminal neuralgia 6, 2
• Photophobia and wind sensitivity - characteristic of neuropathic ocular pain 6, 2
• Prior ocular surgery, infection, or chronic dry eye - predisposing factors for neuropathic ocular pain 6, 2
• Symptoms significantly outweighing clinical signs - key feature of neuropathic ocular pain 2

Essential Physical Examination

• Visual acuity assessment - baseline measurement critical for all patients 1, 3
• Pupillary examination - look for relative afferent pupillary defect 1
• Slit-lamp biomicroscopy - rule out anterior segment inflammation, corneal pathology 1, 3
• Intraocular pressure measurement - exclude acute angle-closure glaucoma 3

Diagnostic Testing Based on Clinical Presentation

For Pain Worsening with Eye Movement

• Brain MRI with and without contrast - essential to evaluate for demyelinating lesions in suspected optic neuritis 1
• Orbital MRI with and without contrast - optimal for localizing and characterizing orbital inflammatory lesions 1
• Ultrasonography - may show fluid in sub-Tenon space (T-sign) in posterior scleritis 1

For Suspected Neuropathic Ocular Pain

Anesthetic challenge test - perform when pain is present before anesthetic placement: 6, 2

• Pain improvement after topical anesthetic → peripheral neuropathic or nociceptive component
• Persistent pain after topical anesthetic → central or non-ocular cause

Management Algorithm

Inflammatory Conditions

Posterior scleritis: Systemic corticosteroids as first-line treatment 1

Tolosa-Hunt syndrome: Highly responsive to corticosteroids but remains a diagnosis of exclusion after ruling out other causes 4

Neuropathic Ocular Pain

Treatment depends on localization of nerve dysfunction: 6, 2

For peripheral neuropathic component:

• Autologous serum tears for nerve regeneration 6, 2

For central component or systemic comorbidities:

• Oral neuromodulators: pregabalin, gabapentin, duloxetine, amitriptyline, nortriptyline, or low-dose naltrexone 6, 2
• Critical expectation setting: Requires 3-4 months at therapeutic dose to see pain reduction 6

For photophobia and headache:

• Transcutaneous electrical nerve stimulation device 6, 2
• Periorbital botulinum toxin A injections 6, 2

For cutaneous allodynia or postsurgical pain:

• Periocular nerve blocks with corticosteroid and long-acting sodium channel blocker 6, 2

Multidisciplinary Approach Required

Neuropathic ocular pain warrants involvement of ophthalmology, pain specialists, neurology, and mental health professionals due to high rates of comorbid anxiety and depression affecting treatment outcomes. 6, 2

Complementary therapies including acupuncture, cognitive behavioral therapy, or hypnosis should be considered as adjuncts. 6

Common Pitfalls to Avoid

• Do not delay ophthalmology referral when red flags are present - conditions like optic neuritis, acute angle-closure glaucoma, and orbital cellulitis require urgent specialist evaluation 3, 5
• Do not attribute all periorbital pain to sinusitis or tension headache without proper examination - inflammatory eye disease accounts for 69% of eye pain cases in ophthalmology clinics 7
• Do not discontinue neuromodulators prematurely - patients must understand the 3-4 month timeline for therapeutic effect 6
• Do not overlook giant cell arteritis in patients >50 years - this can be mistaken for temporomandibular disorders with devastating consequences 6