Can astigmatism (a refractive error) cause eye pain or discomfort?

Can Astigmatism Cause Eye Pain?

Yes, astigmatism can indirectly cause eye pain and discomfort, primarily through asthenopic symptoms (eye strain) from uncorrected refractive error, though astigmatism itself does not directly damage ocular structures. 1

Mechanism of Pain and Discomfort

Uncorrected astigmatism leads to eye pain through several pathways:

• Ocular-motor dysfunction from attempting to compensate for blurred vision can cause frontal headaches and eye pain/pressure behind the eyes 1
• Asthenopic symptoms develop as the ciliary muscles work excessively to achieve clear focus, resulting in eye strain, discomfort, and fatigue 2
• Vision-related quality of life deterioration occurs with uncorrected astigmatism, manifesting as decreased vision quality, increased glare (53-77% of patients), and haloes (28-80% of patients) 2

Clinical Presentation

The discomfort associated with astigmatism typically presents as:

• Eye strain and fatigue rather than acute pain
• Frontal headaches that worsen with visual tasks 1
• Foreign-body sensation in some cases
• Night-time visual difficulties (66% report problems with night driving) 2

Important caveat: If a patient presents with true eye pain (sharp, severe, or associated with redness), consider alternative diagnoses beyond simple astigmatism, as refractive error alone does not cause inflammatory or neuropathic pain.

Treatment Algorithm

First-line treatment is optical correction with eyeglasses before considering contact lenses or refractive surgery 1, 3

For Low to Moderate Astigmatism (<3.00 diopters):

• Soft toric contact lenses or rigid gas-permeable contact lenses are effective options 4, 1
• Full cylindrical correction may not be needed initially in adults with previously uncorrected astigmatism 4, 1
• Gradual correction is better tolerated in adults who have not worn corrective lenses previously, as substantial changes in axis or power are poorly accepted 1, 3

For High Astigmatism (≥3.00 diopters):

• Rigid gas-permeable and hybrid contact lenses with bitoric or back-surface toric designs provide optimal correction 1, 3
• Custom-designed soft toric lenses or RGP scleral lenses (diameter >17mm) are excellent for high and/or irregular astigmatism 1, 3

Common Pitfalls to Avoid

• Do not attempt full cylindrical correction immediately in adults with previously uncorrected astigmatism, as this leads to poor tolerance and patient dissatisfaction 3
• Recognize that irregular astigmatism (seen in keratoconus, corneal scarring, post-surgical corneas) cannot be fully corrected with spherocylindrical lenses and requires specialty contact lenses or surgical intervention 4, 3
• Do not overlook coexisting conditions such as dry eye, which can exacerbate discomfort in astigmatic patients 2

Performance Impact

Uncorrected astigmatism has measurable functional consequences:

• Patients with 1 diopter of astigmatism perform vision-related tasks 9% slower and make 38% more errors 2
• Patients with 2 diopters perform tasks 29% slower and make 370% more errors compared with fully corrected individuals 2
• This translates to increased spectacle dependence (45-85% of patients) and decreased productivity 2