Can elevated intraocular pressure cause eye pain in a patient with symptoms of a swollen, red, watering, and painful burning eye?

Can Elevated Intraocular Pressure Cause Eye Pain?

Yes, elevated intraocular pressure can absolutely cause eye pain, particularly when the elevation is acute and severe, though chronic elevation in open-angle glaucoma typically does not cause pain. 1, 2

When Elevated IOP Causes Pain: Acute Presentations

Acute Angle-Closure Crisis

• Sudden, severe eye pain with IOP typically >40 mmHg is the hallmark presentation of acute angle-closure glaucoma, accompanied by nausea, vomiting, blurred vision, halos around lights, conjunctival redness, corneal edema, and a mid-dilated, poorly reactive pupil 1, 2
• This represents a true ophthalmic emergency requiring immediate treatment, as 18% of untreated eyes become blind and 48% develop glaucomatous optic neuropathy within 4-10 years 2
• The fellow eye has a 50% risk of acute crisis within 5 years if prophylactic treatment is not performed 2

Intermittent Angle Closure

• Transient episodes of eye pain with halos around lights that resolve spontaneously are pathognomonic for intermittent angle closure and represent warning episodes before potentially blinding acute attacks 2, 3
• These patients require urgent ophthalmology referral and gonioscopy even when asymptomatic between episodes, as standard examination may appear normal 3

Acute IOP Elevation from Other Causes

• Acutely elevated IOP from uveitis, trauma, or postoperative spikes can cause significant pain, with IOPs ranging from 38-68 mmHg reported to cause acute optic nerve injury with disc edema and afferent pupillary defects 4
• Elevated IOP occurs in 28% of patients with active microbial keratitis (mean 29.1 mmHg, range 22-51 mmHg) and is associated with poorer outcomes 5
• Secondary glaucoma from uveitis develops in 21.9% of cases overall, with 13.7% in acute uveitis and 26.8% in chronic uveitis 6

When Elevated IOP Does NOT Typically Cause Pain

Primary Open-Angle Glaucoma

• Chronic elevation of IOP in primary open-angle glaucoma is typically painless, which is why it is often called the "silent thief of sight" 1
• Nearly 40% of patients with characteristic glaucomatous optic neuropathy do not have elevated IOP measurements 1
• The disease progresses insidiously without symptoms until significant visual field loss occurs 1

Critical Clinical Decision Points

Immediate Ophthalmology Referral Required If:

• Mid-dilated, poorly reactive, or oval pupil on examination 1, 2
• Severe eye pain with conjunctival injection, corneal edema, and decreased vision 1
• IOP >30 mmHg or any elevation with optic disc changes 2
• Transient episodes of pain with halos around lights, even if resolved 2, 3

Essential Examination Components:

• Visual acuity testing as baseline 2, 3
• Pupil examination for reactivity and afferent pupillary defects 1, 2
• Slit-lamp biomicroscopy for corneal edema, anterior chamber depth, and inflammation 1
• IOP measurement is mandatory in any patient with eye pain and redness 1, 2
• Gonioscopy if angle closure is suspected 1, 3

Common Pitfalls to Avoid

• Never dismiss transient symptoms as benign—they may represent warning episodes before acute angle-closure crisis 2
• Do not assume normal IOP rules out glaucoma—40% of open-angle glaucoma patients have normal pressure 1
• Recognize that pain severity does not always correlate with IOP level—chronic elevation may be painless while acute elevation causes severe pain 1
• Always check IOP in patients on topical corticosteroids, as steroid-induced elevation is common and can be asymptomatic initially 1, 7
• Do not delay fellow eye prophylaxis after treating acute angle closure in one eye 2

Context for Your Patient's Symptoms

In a patient presenting with a swollen, red, watering, and painful burning eye, elevated IOP should be strongly considered and measured immediately. The combination of pain, redness, and swelling could represent acute angle-closure glaucoma, acute uveitis with secondary IOP elevation, or infectious keratitis with elevated pressure 1, 2, 5. The burning quality of pain might also suggest corneal involvement or dry eye, but IOP measurement is essential to rule out vision-threatening causes 2, 3.