Eye Pain: Immediate Assessment and Management
If you're experiencing eye pain, immediately assess for vision-threatening emergencies by checking your vision, looking for pupil abnormalities, and determining if you have severe photophobia—these red flags require same-day ophthalmology evaluation. 1
Critical Red Flags Requiring Emergency Evaluation (Within 24 Hours)
You need immediate medical attention if you have any of these features:
- Vision loss or blurred vision that doesn't clear with blinking 1
- Mid-dilated, poorly reactive, or oval-shaped pupil (suggests acute angle-closure glaucoma) 1
- Severe photophobia (extreme light sensitivity) with pain 1
- Periorbital swelling with restricted eye movement (suggests orbital cellulitis) 1
- High-velocity eye injury from grinding, nailing, or machinery 2
- Penetrating injury from sharp or metal objects 2
- Eye bleeding after trauma or irregular pupil shape 2
- Halos around lights with transient vision loss (50% risk of acute crisis within 5 years if untreated) 1
Non-Emergency Conditions That Still Require Ophthalmology Referral
Foreign Body Sensation
- Persistent foreign-body sensation after attempting irrigation requires medical evaluation 2
- For low-energy foreign bodies (dust, eyelash), first try natural tears or tap water irrigation 2
- Take over-the-counter acetaminophen or NSAIDs for residual discomfort after removal 2
Dry Eye Syndrome
- Presents with burning, stinging pain that worsens later in the day, exacerbated by wind, air travel, and prolonged screen time 1
- Symptoms often outweigh visible signs on examination 2, 1
- Start with preservative-free lubricants 2-4 times daily 2
- Add olopatadine twice daily if moderate symptoms persist 2
- Consider tacrolimus ointment to lid margins once daily for severe cases, but seek ophthalmology advice first 2
Neuropathic Ocular Pain
This is commonly misdiagnosed and should be suspected when:
- Pain persists despite resolution of visible eye problems 2, 3
- Pain described as burning, stinging, or aching with wind sensitivity 2, 3
- History of prior eye surgery, infection, or chronic dry eye 3
Diagnostic test: The anesthetic challenge test differentiates pain types—if topical anesthetic relieves pain, it suggests peripheral nerve involvement; if pain persists, it indicates central sensitization 2, 3
Treatment approach:
- Peripheral component: Autologous serum tears 3
- Central component: Oral neuromodulators (pregabalin, gabapentin, duloxetine, amitriptyline, nortriptyline, or low-dose naltrexone) 3
- With photophobia/headache: Transcutaneous electrical nerve stimulation or periorbital botulinum toxin A 3
- Postsurgical pain: Periocular nerve blocks with corticosteroid and long-acting sodium channel blocker 3
Common Pitfalls to Avoid
- Never dismiss transient symptoms (brief episodes of blurred vision with halos)—these represent warning episodes before potentially blinding acute attacks 1
- Don't delay evaluation of elevated eye pressure—18% risk of blindness within 4-10 years if untreated 1
- Avoid fluorescein-anesthetic combination drops for diagnostic testing 1
- Don't start treatment before establishing diagnosis in patients with blurred vision, pain, and photophobia 1
When Systemic Conditions May Be the Cause
Consider non-eye causes if:
- Unilateral retroorbital pain with pancytopenia (rare Erdheim-Chester disease requires hematology referral) 4
- Associated with fibromyalgia, depression, anxiety, or migraine—these patients respond poorly to standard dry eye treatments and need multidisciplinary pain management 3
- Temporal headache in patients over 50—giant cell arteritis requires urgent corticosteroids 5