Eye pain is a common presentation with a broad differential. A structured history is essential to identify sight-threatening and systemic causes. It is important to ask about eye pain when taking an ophthalmic history, even if it is not the presenting complaint.
Contents
Presenting Complaint: Eye Pain
Start with an open question
- “Can you tell me more about the eye pain?”
Allow the patient to describe symptoms in their own words before focusing the history
A useful framework to explore eye pain is NOTEPAD
N – Nature
- Which eye(s)?
- Usually unilateral: acute angle-closure glaucoma, keratitis, optic neuritis, orbital cellulitis
- Unilateral or bilateral: conjunctivitis, uveitis, scleritis, dry eye syndrome
- Character of pain
- Sharp/foreign body sensation → corneal abrasion, foreign body
- Gritty → dry eye, conjunctivitis, keratitis, blepharitis
- Deep, boring pain → scleritis
- Severe intense pain → acute angle-closure glaucoma
- Retro-orbital pain → optic neuritis
- Severity (mild–severe, pain score)
O – Onset
- When did the pain start?
- Sudden or gradual onset?
- Sudden onset: acute angle-closure glaucoma, corneal abrasion, keratitis, foreign body
- Subacute/gradual (hours–days): uveitis, scleritis, optic neuritis
- Any previous episodes?
- Precipitating factors:
- Trauma → foreign body. Skin trauma is a risk factor for preseptal cellulitis.
- Chemical injury
- Recent illness/viral prodrome → viral conjunctivitis, preseptal cellulitis, orbital cellulitis
- Fresh water or soil exposure → amoebic keratitis
- Plant/soil trauma → fungal keratitis
T – Timing
- Duration of symptoms
- Is the pain persistent or intermittent?
E – Exacerbating / Relieving Factors
- Does anything make the pain better or worse?
- Worse with eye movement → optic neuritis, orbital cellulitis, scleritis
- Worse with light (photophobia) → keratitis, uveitis, scleritis
- Worse with palpation → scleritis, orbital cellulitis
- Worse in dark environments → acute angle-closure glaucoma (pupillary dilation)
P – Progression
- Explore whether the patient’s symptoms are improving, static, or worsening and how they are changing
A – Associated Symptoms
Ophthalmic
- Reduced or blurred vision
- Halos around lights → acute angle-closure glaucoma
- Red eye
- Foreign body sensation/grittiness
- Itching → allergic or viral conjunctivitis
- Discharge from eye:
- Purulent → bacterial conjunctivitis
- Watery → viral conjunctivitis, allergic conjunctivitis, keratitis, dry eye syndrome
- Photophobia → keratitis, uveitis, scleritis
- Flashes and floaters
- Swelling or tenderness around the eye → orbital cellulitis
Systemic
- Headache
- Nausea/vomiting → acute angle-closure glaucoma
- Fever/systemic illness → orbital cellulitis, preseptal cellulitis
- Joint pain or stiffness → dry eye syndrome, scleritis, episcleritis, and uveitis may be associated with rheumatoid arthritis, spondyloarthropathies
- Bowel symptoms → dry eye syndrome, scleritis, episcleritis, and uveitis may be associated inflammatory bowel disease
- Neurological symptoms (weakness, paraesthesia) → optic neuritis is most commonly associated with underlying demyelinating conditions
D – Disability
- Impact on:
- Daily activities
- Employment
- Driving (may need to stop and notify DVLA if vision affected)
Red Flags 🚩 (Urgent Ophthalmology Review)
- Sudden severe eye pain
- Severe eye pain following recent ophthalmic surgery
- Reduced or rapidly worsening vision
- History of trauma or chemical exposure
- Pain on eye movement
- Immunocompromised patient
- Systemic features (e.g. fever)
Background History
Past Ocular History
- Previous eye disease or surgery
- Trauma
- Refractive error (myopia/hyperopia)
- Contact lens use:
- Type (daily/monthly/extended wear)
- Hygiene
- Sleeping, swimming, or showering with lenses
(Major risk factor for keratitis)
- Acute severe pain post-surgery → consider endophthalmitis
Past Medical History
- Other medical conditions
- Autoimmune disease (RA, IBD, spondyloarthropathies) – associated with dry eye syndrome, uveitis, scleritis, episcleritis
- Diabetes or other causes of immunosuppression – increases risk of infections e.g. fungal keratitis, reactivation of herpes.
- History of herpes simplex infection → herpes keratitis
Drug History
- Topical or systemic steroids – increases IOP, can immunosuppress patients
- Isotretinoin – increases risk of dry eye syndrome
- Drug allergies
Social History
- Occupation – consider occupational hazards e.g. construction work may increase risk of ocular injury by foreign bodies
- Contact with unwell people
- Smoking and alcohol
- Sexual history if chlamydial conjunctivitis suspected
- Living situation and support at home
Family History
- Family history of eye disease e.g. glaucoma
- Family history of autoimmune conditions
Common Differentials
Below is a list of common differentials for eye pain, organised by ocular anatomy
| Condition | Key features |
| Conjunctiva | |
| Conjunctivitis | Bacterial conjunctivitis: – Gritty sticky eyes – Red eye – Purulent discharge – Mild pain/irritation Viral conjunctivitis: – Watery discharge – Mild pain/irritation – Recent upper respiratory infection – Highly contagious |
| Cornea | |
| Keratitis | Acutely red painful eye, photophobia, foreign body/gritty sensation, blurry/reduced vision Causes include: – Bacterial – Viral – Fungal – history of trauma with plants/soil or immunosuppression – Amoebic – infection is associated with exposure to fresh water or soil Contact lens wear is a significant risk factor |
| Corneal abrasion | – Sharp pain – Foreign body sensation – Preceding trauma |
| Dry eye syndrome | – Gritty irritated red eyes, mild pain/discomfort – Can cause watery eyes – Temporary blurriness that clears with blinking |
| Sclera and episclera | |
| Scleritis | – Painful eye (ranging from mild pain/discomfort to deep boring eye pain) – Diffusely red eye – Watering and photophobia – Tender globe – Reduced vision – Pain can be worse with eye movements – Significant proportion of patients with scleritis have associated systemic disease e.g. rheumatoid arthritis, SLE, IBD, spondyloarthropathies, infectious disease (e.g. TB, syphilis) |
| Episcleritis | – Red eye – Mild pain/irritation – Watering and photophobia may be present – Episcleritis can be associated with systemic disease (e.g. rheumatoid arthritis, IBD) but most cases are idiopathic and self-limiting |
| Anterior chamber | |
| Acute angle closure glaucoma | – Acute onset severe eye pain – Red eye – Decreased visual acuity – Haloes around lights – Systemic upset may be seen e.g. abdominal pain, nausea and vomiting – Symptoms worse with mydriasis e.g. watching TV in a dark room – Risk factors include hypermetropia, East Asian descent, family history of glaucoma |
| Anterior uveitis | – Acute/subacute onset ocular discomfort/pain – Red eye – Photophobia – Blurred vision – Lacrimation – May be associated with systemic conditions e.g. ankylosing spondylitis, reactive arthritis, IBD, sarcoidosis, Behcet’s disease |
| Others | |
| Orbital cellulitis | – Acute onset painful proptosed eye – Eyelid oedema and erythema – Reduced vision – Ophthalmoplegia/pain with eye movements – May be associated with systemic upset e.g. fever – Predominantly affects children – Usually caused by spreading upper respiratory tract infection from adjacent sinuses |
| Preseptal cellulitis | – Acute onset red, swollen, painful eye – Eyelid oedema and erythema Possible associated systemic symptoms e.g. fever – No pain on eye movement, restriction of eye movements, visual disturbances – Predominantly affects children – Infection commonly from skin trauma or local infections e.g. respiratory tract infections/sinusitis |
| Endophthalmitis | – Acute severe eye pain – Red eye – Photophobia – Reduced vision – Majority of cases occur following ophthalmic surgery |
| Optic neuritis | – Subacute unilateral loss of vision – Eye pain worse with eye movements – Reduced colour vision – Most commonly associated with demyelinating condition (e.g. multiple sclerosis) – history may include other neurological symptoms e.g. paraesthesia, weakness – Uhthoff’s phenomenon – worsening of vision following rise in body temperature e.g. exercise |
References
1. Bowling B. Kanski’s Clinical Ophthalmology: A Systematic Approach. 9th ed. London: Elsevier; 2019
2. Denniston A, Murray P, editors. Oxford Handbook of Ophthalmology. 4th ed. Oxford: Oxford University Press; 2018.
3. American Academy of Ophthalmology. Basic Ophthalmology: Essentials for Medical Students. 11th ed. San Francisco: American Academy of Ophthalmology; 2016.
4. Shah P, Shah S. The Duke-Elder Exam of Ophthalmology: A Comprehensive Guide. 2nd ed. Boca Raton: CRC Press; 2021.
- Author – Dr Wei Jia Liu
- Editor – Dr Daniel Arbide
