Presentations / Eye pain and photophobia
Eye pain and photophobia
Surface, uvea, pressure, nerve, or referred.
The character of the pain names the layer. A gritty, foreign-body pain that improves with an anaesthetic drop is the surface. A deep ache with photophobia is the uvea. A severe ache with headache and vomiting is the pressure. Pain on moving the eye is the nerve or the orbit.
A white level in a painful eyeOpen in the atlas
By the character of the pain
The anaesthetic drop test is decisive for the surface: if a drop of topical anaesthetic abolishes the pain, the problem is the cornea or conjunctiva (abrasion, foreign body, keratitis, dry eye). Deeper pain does not respond.
| Layer | The pain | With | The cause |
|---|---|---|---|
| Surface | Gritty, foreign body, worse blinking; relieved by anaesthetic | Watering, photophobia | Abrasion, foreign body, keratitis, dry eye, welder's flash |
| Uvea | Deep, dull ache | Marked photophobia, ciliary flush, small pupil | Anterior uveitis |
| Pressure | Severe ache and headache | Nausea, vomiting, haloes, a hard eye | Acute angle closure |
| Sclera | Boring, wakes the patient, tender globe | Deep violaceous redness | Scleritis |
| Nerve | Pain on eye movement | Reduced vision, colour loss, RAPD | Optic neuritis |
| Orbit | Pain on movement, proptosis | Fever, restricted movement | Orbital cellulitis, orbital inflammation |
| Referred | Around the eye with a normal eye | Autonomic features, a pattern | Cluster headache, migraine, sinusitis, zoster before the rash |
Photophobia without a red eye
Ultraviolet keratitis (welder's flash, a sunbed, snow) arrives hours after the exposure: both eyes, intense pain, photophobia and watering, with fine punctate staining across both corneas. It heals in a day or two with lubricants and the lights off. Migraine, meningitis and a subarachnoid haemorrhage cause photophobia with normal eyes: the rest of the history decides.
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