Eye pain [Ophthalmalgia]

Eye pain [Ophthalmalgia]: Excerpt from Professional Guide to Signs & Symptoms (Fifth Edition)

Eye pain may be described as a burning, throbbing, aching, or stabbing sensation in or around the eye. It may also be characterized as a foreign-body sensation. This sign varies from mild to severe; its duration and exact location provide clues to the causative disorder.

Eye pain usually results from corneal abrasion, but it may also be due to glaucoma or other eye disorders, trauma, and neurologic or systemic disorders. Any of these may stimulate nerve endings in the cornea or external eye, producing pain.

Emergency interventions

History and physical examination

If the patient’s eye pain doesn’t result from a chemical burn or from acute angle-closure glaucoma, take a complete history. Have the patient describe the pain fully. Is it an ache or a sharp pain? How long does it last? Is it accompanied by burning, itching, or a discharge? Find out when it began. Is it worse in the morning or late in the evening? Ask about recent trauma or surgery, especially if the patient complains of severe pain that developed suddenly. Does he have headaches? If so, find out how often and at what time of day they occur.

During the physical examination, don’t manipulate the eye if you suspect trauma. Carefully assess the eyelids and conjunctivae for redness, inflammation, and swelling. Then examine the eyes for ptosis or exophthalmos. Finally, test visual acuity with and without correction, and assess extraocular movements. Characterize any discharge. (See Examining the external eye, page 322.)

Medical causes

Acute angle-closure glaucoma

Blurred vision and sudden excruciating pain in and around the eye characterize this disorder; the pain may be so severe that it causes nausea, vomiting, and abdominal pain. Other findings are halo vision, rapidly decreasing visual acuity, and a fixed, nonreactive, moderately dilated pupil.

Astigmatism

Uncorrected astigmatism commonly causes headaches and eye fatigue, aching, and redness. This disorder occurs in both older and younger people.

Blepharitis

Burning pain in both eyelids is accompanied by conjunctival injection and an itching, sticky discharge. Related findings include a foreign-body sensation, eyelid ulcerations, and loss of eyelashes.

Burns

In chemical burns, sudden severe eye pain may occur with erythema and blistering of the face and eyelids, photophobia, miosis, conjunctival injection, blurring, and inability to keep the eyelids open. In ultraviolet radiation burns, moderate to severe pain occurs about 12 hours after exposure along with photophobia and vision changes.

Chalazion

A chalazion causes localized tenderness and swelling on the upper or lower eyelid. Eversion of the lid reveals conjunctival injection and a small red lump.

Conjunctivitis

Some degree of eye pain and excessive tearing occur in four types of conjunctivitis. Allergic conjunctivitis causes mild, burning, bilateral pain accompanied by itching, conjunctival injection, and a characteristic ropey discharge.

Bacterial conjunctivitis causes pain only when it affects the cornea. Otherwise, it typically produces burning, a foreign-body sensation, a purulent discharge, and conjunctival injection.

If the cornea is affected, fungal conjunctivitis may cause pain and photophobia. Without corneal involvement, it produces itching, burning eyes; a thick, purulent discharge; and conjunctival injection.

Viral conjunctivitis produces itching, red eyes; a foreign-body sensation; visible conjunctival follicles; and eyelid edema.

Corneal abrasions

This type of injury typically produces a foreign-body sensation, excessive tearing, photophobia, and conjunctival injection.

Corneal erosion (recurrent)

In this disorder, severe pain occurs on waking and continues throughout the day. Accompanying the pain are conjunctival injection and photophobia.

Corneal ulcers

Both bacterial and fungal corneal ulcers cause severe eye pain. They may also cause a purulent eye discharge, sticky eyelids, photophobia, and impaired visual acuity. In addition, bacterial corneal ulcers produce a grayish white, irregularly shaped ulcer on the cornea; unilateral pupil constriction; and conjunctival injection. Fungal corneal ulcers produce conjunctival injection, eyelid edema and erythema, and a dense, cloudy, central ulcer surrounded by progressively clearer rings.

Dacryoadenitis

Temporal pain may affect both eyes in this disorder. Associated findings include exophthalmos, conjunctival injection, severe eyelid erythema and edema, and a purulent eye discharge.

Dacryocystitis

Pain and tenderness near the tear sac characterize acute dacryocystitis. Additional signs include excessive tearing, a purulent discharge, eyelid erythema, and swelling around the lacrimal punctum.

Episcleritis

Deep eye pain occurs as tissues over the sclera become inflamed. Related effects include photophobia, excessive tearing, conjunctival edema, and a red or purplish sclera.

Erythema multiforme major

This disorder commonly produces severe eye pain, entropion, trichiasis, purulent conjunctivitis, photophobia, and decreased tear formation.

Foreign bodies in the cornea and conjunctiva

Sudden severe pain is common in this condition, but vision usually remains intact. Other findings include excessive tearing, photophobia, miosis, a foreign-body sensation, a dark speck on the cornea, and dramatic conjunctival injection.

Glaucoma

Open-angle glaucoma may cause mild aching in the eyes as well as loss of peripheral vision, halo vision, and reduced visual acuity that isn’t corrected by glasses. Acute angle-closure glaucoma may cause severe pain and pressure over the eye, blurred vision, halo vision, decreased visual acuity, and nausea and vomiting.

Herpes zoster ophthalmicus

Eye pain occurs with severe unilateral facial pain, usually several days before vesicles erupt. Other signs include red, swollen eyelids; excessive tearing; a serous eye discharge; conjunctival injection; and a white, cloudy cornea.

Hordeolum (stye)

This lesion usually produces localized eye pain that increases as the stye grows. Eyelid erythema and edema are also common.

Hyphema

Occurring after eye injury or surgery, hyphema accompanies sudden pain in and around the eye. Orbital and eyelid edema, conjunctival injection, and visual impairment may also occur.

Interstitial keratitis

Associated with congenital syphilis, this corneal inflammation produces eye pain with photophobia, blurred vision, prominent conjunctival injection, and grayish pink corneas.

Iritis (acute)

Moderate to severe eye pain occurs with severe photophobia, dramatic conjunctival injection, and blurred vision. The constricted pupil may respond poorly to light.

Keratoconjunctivitis sicca

This condition—known as dry eye syndrome—causes chronic burning pain in both eyes, itching, a foreign-body sensation, photophobia, dramatic conjunctival injection, and difficulty moving the eyelids. A copious mucoid discharge and inadequate tearing are typical.

Lacrimal gland tumor

This neoplastic lesion usually produces unilateral eye pain, impaired visual acuity, and some degree of exophthalmos.

Migraine headache

Migraines can produce head pain so severe that the eyes also ache. Nausea, vomiting, blurred vision, and light and noise sensitivity may also occur.

Ocular laceration and intraocular foreign bodies

Penetrating eye injuries usually cause mild to severe unilateral eye pain and impaired visual acuity. Eyelid edema, conjunctival injection, and an abnormal pupillary response may also occur.

Optic cellulitis

This disorder causes dull, aching pain in the affected eye, some degree of exophthalmos, eyelid edema and erythema, a purulent discharge, impaired extraocular movement and, occasionally, decreased visual acuity and fever.

Optic neuritis

In this disorder, pain in and around the eye occurs with eye movement. Severe vision loss and tunnel vision develop but improve in 2 to 3 weeks. Pupils respond sluggishly to direct light but normally to consensual light.

Orbital floor fracture

Sometimes called a blowout fracture, this injury causes eye pain, dramatic eyelid edema and, possibly, enophthalmos and diplopia.

Orbital pseudotumor

This disorder causes deep, boring eye pain and diplopia in about 50% of patients. However, prominent exophthalmos and lateral ocular deviation are more characteristic. Eyelid edema and limited extraocular movement may also occur.

Pemphigus

In this disorder, bilateral eye pain and irritation may be accompanied by blurred vision and a thick discharge. Blisters may develop on the conjunctiva alone or may extend to the nasal, oral, and vulvar mucous membranes as well as the skin.

Scleritis

This inflammation produces severe eye pain and tenderness, conjunctival injection, bluish purple sclera and, possibly, photophobia and excessive tearing.

Sclerokeratitis

Inflammation of the sclera and cornea causes pain, burning, irritation, and photophobia.

Subdural hematoma

Following head trauma, a subdural hematoma commonly causes severe eye ache and headache. Related neurologic signs depend on the hematoma’s location and size.

Trachoma

Along with pain in the affected eye, trachoma causes excessive tearing, photophobia, an eye discharge, eyelid edema and erythema, and visible conjunctival follicles.

Uveitis

Anterior uveitis causes sudden severe pain, dramatic conjunctival injection, photophobia, and a small, nonreactive pupil.

Posterior uveitis causes insidious onset of similar features, plus gradual blurring of vision and distorted pupil shape.

Lens-induced uveitis causes moderate eye pain, conjunctival injection, pupil constriction, and severely impaired visual acuity. In fact, the patient usually can perceive only light.

Other causes

Treatments

Contact lenses may cause eye pain and a foreign-body sensation. Ocular surgery may also produce eye pain, ranging from a mild ache to a severe pounding or stabbing sensation.

Special considerations

To help ease eye pain, have the patient lie down in a darkened, quiet environment and close his eyes. Prepare him for diagnostic studies, including tonometry and orbital X-rays.

Pediatric pointers

Trauma and infection are the most common causes of eye pain in children. Be alert for nonverbal clues to pain, such as tightly shutting or frequently rubbing the eyes.

Geriatric pointers

Glaucoma, which can cause eye pain, usually affects older patients, becoming clinically significant after age 40. It usually occurs bilaterally and leads to slowly progressive vision loss, especially in peripheral visual fields.

Patient counseling

Tell the patient to seek medical help for eye pain, and stress the importance of meticulous compliance with drug therapy to prevent an increase in IOP.

Pictures

Book Source Details

• Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.

More About Conjunctivitis

• Back to disease: Conjunctivitis: Introduction
• Next Book Extract About Conjunctivitis: Eye Pain (Field Guide to Bedside Diagnosis)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Professional Guide to Signs & Symptoms (Fifth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-510-9

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