Eye pain: causes, diagnosis, treatment

Eye pain is a symptom, not a diagnosis in itself. It can originate from the ocular surface, the cornea, sclera, choroid, anterior chamber, optic nerve, or orbital tissue. Therefore, the same everyday phrase "my eye hurts" could conceal dry eye syndrome or corneal erosion, as well as an acute attack of angle-closure glaucoma, infectious keratitis, anterior uveitis, orbital cellulitis, or optic neuritis. [1]

The key goal for a physician with such a complaint is not simply to relieve pain, but to quickly determine whether the condition is vision-threatening. The American Academy of Family Physicians indicates that conditions requiring an ophthalmologist consultation include acute angle-closure glaucoma, infectious keratitis, anterior uveitis, scleritis, orbital cellulitis, and optic neuritis. [2]

For practitioners, it's important to remember that the severity of pain isn't always directly related to danger, but certain combinations of symptoms are particularly worrisome. The most concerning are pain accompanied by decreased vision, rainbow halos around light sources, severe photophobia, nausea, vomiting, pain with eye movement, fever, eyelid swelling, chemical exposure, or symptoms associated with contact lenses. [3]

A distinct clinical paradox is that some "superficial" diseases are felt very sharply, while some deeper processes can initially masquerade as more benign conditions. This is why a modern article on eye pain should not be structured around a simple list of diseases, but rather a route: what's most likely, what's more dangerous, what to do immediately, and what not to do before an examination. [4]

What exactly can hurt and why is it important?

Most often, the source of pain is the structures of the anterior segment of the eye, primarily the cornea and ocular surface. The cornea is extremely sensitive, so even a small epithelial defect, a foreign body, dry surface, or early keratitis can cause severe pain, lacrimation, eyelid spasms, and photophobia. Therefore, in a patient complaining of a "burning" or "stabbing" pain, the first diagnostic task is a corneal examination and fluorescein staining. [5]

A different type of pain, deeper, boring, or bursting, often suggests scleritis, intraocular inflammation, or a sudden increase in intraocular pressure. Scleritis is characterized by intense, deep pain that can intensify with eye movement and even palpation, and can also be associated with systemic autoimmune diseases. An acute attack of angle-closure glaucoma is characterized by severe pain, blurred vision, halos, headache, nausea, and vomiting. [6]

If the pain intensifies with eye movement, the range of possible causes narrows significantly. This symptom is especially significant for optic neuritis, orbital cellulitis, and scleritis; it can also occur with an acute increase in intraocular pressure. This is why the question "Does it hurt to look to the side?" is of great diagnostic value and is not a mere formality. [7]

Superficial discomfort and burning are not always harmless, but are often associated with dry eye syndrome. The international consensus on dry eye syndrome defines this condition as a multifactorial disorder of the ocular surface with loss of tear film homeostasis, in which tear film instability, hyperosmolarity, ocular surface inflammation, and neurosensory disturbances play a role. This explains why some patients with dry eye experience severe pain and discomfort, and complaints extend beyond a gritty sensation. [8]

Finally, it's important to distinguish pain within the eye itself from pain around the eye. Orbital processes, neuralgia, migraine, cluster headaches, and sinus-related complications can also be perceived as eye pain. However, if the pain is accompanied by ophthalmological signs—decreased vision, photophobia, redness, pain with eye movement, pupil changes, or eyelid swelling—the likelihood of an ocular or orbital cause increases significantly. [9]

Table 1. What types of pain help to suggest the source of the problem

The nature of pain	What is most often suspected?	What usually helps to distinguish
Burning, sandy sensation, dryness	dry eye syndrome, superficial irritation	fluctuating discomfort associated with eye strain, instability of the tear film
Sharp stabbing pain, lacrimation, photophobia	corneal erosion, foreign body, keratitis	fluorescein staining, corneal examination
Deep drilling pain	scleritis	increased with eye movement and palpation, associated with systemic inflammation
Pain with halos, nausea, and blurred vision	acute attack of angle-closure glaucoma	increased intraocular pressure, fixed dilated pupil
Pain when moving the eyes and decreased color vision	optic neuritis	decreased vision, color vision impairment, magnetic resonance imaging
Pain with fever, swelling of the eyelid, limited mobility	orbital cellulitis	computed tomography of the orbits, hospitalization

The table is compiled from clinical reviews of eye pain, data on scleritis, uveitis, optic neuritis and acute attack of angle-closure glaucoma. [10]

The main causes of eye pain and how to distinguish them

Dry eye syndrome is one of the most common causes of chronic burning, irritation, and a foreign body sensation. Symptoms may worsen in the evening, when working at a screen, in dry air, or with infrequent blinking. Despite its prevalence, this condition should not be dismissed as a "minor issue": international consensus emphasizes its inflammatory and neurosensory nature, rather than simply a "lack of tears." [11]

Corneal erosions and superficial foreign bodies typically cause severe pain, lacrimation, photophobia, and a feeling of something in the eye. Diagnosis is confirmed by fluorescein staining. Importantly, with contact lens injuries, the risk of secondary bacterial keratitis is higher, so the treatment approach is more stringent than with a typical minor erosion. Patching is generally not recommended for uncomplicated erosions, as it does not improve pain and may delay healing. [12]

Infectious keratitis is one of the most dangerous causes of eye pain. It can be accompanied by severe pain, redness, photophobia, and decreased vision. The American Academy of Ophthalmology notes that contact lens wear is the leading risk factor for microbial keratitis in the United States, and overnight lens wear significantly increases the risk. In practice, this means a simple rule: pain and redness associated with contact lenses should not automatically be considered "irritation" or "dryness." [13]

Anterior uveitis, an inflammation of the iris and ciliary body, typically presents with a painful, red eye, severe photophobia, and sometimes miosis and pupillary changes. It is often associated with systemic diseases, including seronegative spondyloarthritis, sarcoidosis, syphilis, rheumatoid arthritis, and reactive arthritis. If anterior uveitis is suspected, urgent referral to an ophthalmologist is required, as delayed treatment increases the risk of vision loss and complications. [14]

Scleritis is characterized by deeper, more severe pain. It can radiate to the face, worsen with eye movement, and even wake you at night. This condition is much more serious than episcleritis and is more often associated with autoimmune pathology. An article for clinicians notes that approximately half of patients with scleritis have an associated rheumatological disease, so in true scleritis, not only a local but also a systemic assessment is important. [15]

An acute attack of angle-closure glaucoma is an ophthalmologic emergency. It presents with severe pain, blurred vision, halos around lights, headache, nausea, and vomiting. The American Academy of Ophthalmology emphasizes that an acute attack requires urgent reduction of intraocular pressure and further interventions, including laser peripheral iridotomy or other methods as appropriate. [16]

Optic neuritis often causes pain with eye movement rather than pronounced redness, accompanied by subacute vision loss, impaired color perception, and central visual complaints. Assessment of pupillary responses, color vision, and magnetic resonance imaging of the orbits and brain are particularly important for diagnosis. The Cleveland Clinic clinical guidelines state that orbital magnetic resonance imaging with contrast and fat suppression typically reveals enlargement and contrast enhancement of the affected optic nerve in the acute phase. [17]

Orbital cellulitis is another cause of pain that should not be ignored. It is characterized by unilateral swelling and redness of the eyelids, ptosis, pain with eye movement, limited mobility, sometimes double vision, proptosis, fever, and decreased vision. This condition requires hospitalization, intravenous antibiotics, and a CT scan of the orbits and paranasal sinuses. [18]

Table 2. Main causes of eye pain and characteristic symptoms

Cause	What are the most common complaints?	What is particularly alarming
Dry eye syndrome	burning, sand, intermittent fogging	chronic course, discomfort from screens and dry air
Corneal erosion	sharp pain, lacrimation, photophobia	trauma, nail, paper, lenses
Infectious keratitis	pain, redness, photophobia, decreased vision	contact lenses, overnight wear, water contact
Anterior uveitis	pain, photophobia, red eye, miosis	pupil changes, systemic inflammatory diseases
Scleritis	deep drilling pain	autoimmune background, pain with eye movement and palpation
Acute attack of angle-closure glaucoma	pain, halos, fog, nausea	a sharp deterioration in vision, pronounced vegetative symptoms
Optic neuritis	pain when moving the eyes, loss of vision	deterioration of color vision, central visual complaints
Orbital cellulitis	pain, swelling of the eyelids, fever	limited eye movement, proptosis, decreased vision

The table summarizes data on the main causes of eye pain from clinical reviews and specialized materials on keratitis, scleritis, uveitis, glaucoma, optic neuritis and orbital cellulitis. [19]

Red Flags: When Urgent Help Is Needed

The most important warning sign is decreased vision accompanied by pain. The American Academy of Family Physicians emphasizes that painful eye conditions accompanied by decreased visual acuity often require urgent ophthalmologic examination, as this can be a manifestation of infectious keratitis, optic neuritis, orbital cellulitis, and acute angle-closure glaucoma. [20]

Severe photophobia is the second important sign. It is particularly typical for keratitis and anterior uveitis, but can also occur with corneal erosions, migraines, and glaucoma. A clinical review noted that the absence of photophobia makes uveitis or keratitis less likely, while the presence of photophobia with pain significantly increases the suspicion of corneal or anterior segment inflammation. [21]

Rainbow-colored halos, severe nausea, and vomiting accompanied by eye pain are a classic combination for an acute attack of closed-angle glaucoma. This condition cannot be treated at home with "redness drops" or analgesics until the next day. It requires urgent reduction of intraocular pressure and an immediate examination by an ophthalmologist. [22]

Pain with eye movement, especially if accompanied by eyelid swelling, fever, limited motion, double vision, or proptosis, requires the exclusion of orbital cellulitis. If there is no significant eyelid swelling, but there is subacute visual impairment and color vision impairment, optic neuritis should be considered. In both cases, delay is dangerous. [23]

Contact lenses, chemical burns, and herpes zoster rashes on the forehead or nasal area should be treated with particular caution. Contact lenses increase the risk of infectious keratitis. In the case of a chemical burn, the first step should be immediate, copious irrigation of the eye. For ophthalmic herpes zoster, antiviral therapy is most effective if started within the first 72 hours of the rash's onset. [24]

Table 3. Red flags for eye pain

Symptom	Why is this dangerous?	What to do
Decreased vision	possibly sight-threatening condition	consult an ophthalmologist immediately
Severe photophobia	keratitis or uveitis are possible	same-day urgent examination
Rainbow halos, nausea, vomiting	typical for an acute attack of angle-closure glaucoma	urgent Care
Pain when moving eyes	optic neuritis, scleritis, and orbital cellulitis are possible	urgent assessment
Fever, eyelid edema, proptosis	orbital cellulitis is possible	hospitalization and visualization
Contact lenses and severe pain	risk of microbial keratitis	remove lenses immediately and consult a doctor
Chemical exposure	risk of rapid corneal damage	rinse your eye immediately and go get help
Herpetic rash on the face	risk of ophthalmic herpes zoster	start treatment as early as possible

The table is based on clinical reviews of eye pain, glaucoma, orbital cellulitis, corneal lesions, contact lenses, and herpetic ocular lesions.[25]

Diagnostics: What's Really Important During a Consultation

Diagnosis begins with a brief but very detailed medical history. The doctor specifies the nature of the pain, its onset, the presence of photophobia, foreign body sensation, decreased vision, double vision, headache, nausea, trauma, contact lenses, chemical exposure, herpes outbreaks, autoimmune diseases, and systemic infections. This survey is not a set procedure: it immediately helps narrow the range of causes and determine the urgency. [26]

Next, visual acuity is assessed. This is one of the most important parameters, as it quickly differentiates surface irritation from conditions that are potentially vision-threatening. The same clinical review emphasizes that examination of the painful eye should include a systematic assessment of the conjunctiva, eyelids, sclera, cornea, pupil, anterior chamber, and anterior choroid, as well as, if necessary, fluorescein staining and intraocular pressure measurement. [27]

Fluorescein staining is especially important in cases of suspected corneal erosion, superficial foreign body, herpetic keratitis, and other epithelial defects. In cases of erosion, the defect becomes visible in blue light, and the branching pattern suggests a herpetic lesion. The upper eyelid is often everted to avoid missing a hidden foreign body. [28]

Measuring intraocular pressure is important if glaucoma is suspected, but penetrating trauma must first be ruled out. A painful, red eye with halos, nausea, and a fixed, dilated pupil increases the likelihood of an acute attack of angle-closure glaucoma, which influences further management within the first few minutes of examination. [29]

If pain with eye movement and visual impairment dominate the clinical picture, neuro-ophthalmological diagnostics become paramount. In such cases, magnetic resonance imaging of the orbits and brain, as well as optical coherence tomography, are used, particularly to distinguish typical demyelinating optic neuritis from other causes of optic neuropathy. If orbital cellulitis is suspected, computed tomography of the orbits and paranasal sinuses is indicated. [30]

Table 4. Basic diagnostic methods for eye pain

Method	What helps to identify	When especially needed
Visual acuity test	the presence of clinically significant visual impairment	all patients with eye pain
Examination of pupils and reactions	afferent defect, anisocoria, signs of uveitis or neuritis	with decreased vision, pain when moving the eyes
Fluorescein staining	erosion, foreign body, epithelial defect, herpetic pattern	for pain, lacrimation, photophobia
Measuring intraocular pressure	acute attack of angle-closure glaucoma	for areolae, nausea, severe pain
Slit lamp	cells and protein in the anterior chamber, keratitis, uveitis, corneal defects	in case of redness, photophobia, decreased vision
Computed tomography of the orbits	orbital cellulitis, sinusogenic complications	with swelling of the eyelids, fever, pain when moving the eyes
Magnetic resonance imaging of the orbits and brain	optic neuritis, other neuro-ophthalmological causes	for pain when moving the eyes and deteriorating vision
Optical coherence tomography	evaluation of optic nerve fibers and retina	if neuritis and its consequences are suspected

The table is based on contemporary clinical reviews of eye pain, corneal erosion, orbital cellulitis, and optic neuritis.[31]

Treatment: tactics depend on the cause

Dry eye syndrome treatment is not limited to artificial tears alone. The international consensus on dry eye syndrome views treatment as a stepwise process: from environmental and habit modification to tear substitutes, treatment of meibomian gland dysfunction, anti-inflammatory therapy, and other methods depending on the disease subtype. This is important because eye pain associated with dry eyes can be a consequence not only of fluid deficiency but also of chronic inflammation of the ocular surface. [32]

In corneal abrasions, the primary goals are pain relief, infection prevention, and epithelial healing. The AAFP review notes that patching is not recommended for uncomplicated abrasions, that topical anesthetics for home use are dangerous due to toxicity and masking of deterioration, and that oral analgesics or a short course of topical nonsteroidal anti-inflammatory drugs may be used for uncomplicated injuries. [33]

If the erosion is associated with contact lenses, the approach becomes more rigorous. These patients require topical medications with antipseudomonal activity, closer monitoring, and a low threshold for referral to an ophthalmologist. Lenses should not be worn until complete healing and symptom resolution, and old lenses and case should be replaced. [34]

For infectious keratitis, treatment should begin promptly and under the supervision of an ophthalmologist. The American Academy of Ophthalmology lists contact lens wear as a major risk factor for microbial keratitis, and therefore, a sore, red eye in contact lens wearers requires a particularly low threshold for antibiotic therapy and urgent examination. Self-treatment with "generic redness drops" in this situation is dangerous. [35]

Anterior uveitis is treated differently than keratitis or dry eye. Topical corticosteroids and cycloplegics are typically the mainstays of treatment, but these should be prescribed by an ophthalmologist after confirming the diagnosis, as inappropriate use of steroids without a diagnosis can be harmful in the case of a painful red eye. In cases of recurrent or bilateral inflammation, a search for a systemic cause is essential. [36]

Scleritis almost never responds to topical treatment. A review of inflammatory eye diseases indicates that it often requires systemic nonsteroidal anti-inflammatory drugs or systemic corticosteroids, and if associated with an autoimmune disease, coordination with a rheumatologist. This is one reason why deep, boring pain should not be confused with superficial irritation. [37]

An acute attack of angle-closure glaucoma requires urgent reduction of intraocular pressure and subsequent intervention, often laser peripheral iridotomy. Orbital cellulitis requires hospitalization, intravenous antibiotics, and imaging. Optic neuritis requires joint management by an ophthalmologist and neurologist, and in the typical demyelinating variant, high-dose corticosteroids are used to accelerate short-term visual recovery. [38]

Table 5. How different causes of eye pain are usually treated

Cause	Basic treatment tactics
Dry eye syndrome	tear substitutes, environmental correction, stepwise treatment of inflammation and dysfunction of the ocular surface
Corneal erosion	pain relief, corneal protection, infection prevention, avoidance of patching in typical uncomplicated cases
Contact lens erosion	antipseudomonal topical medications, avoiding contact lenses until healing, re-examination
Infectious keratitis	urgent ophthalmologic evaluation and topical antimicrobial therapy
Anterior uveitis	topical corticosteroids and cycloplegics as prescribed by an ophthalmologist
Scleritis	systemic anti-inflammatory therapy, search for an autoimmune cause
Acute attack of angle-closure glaucoma	urgent reduction of intraocular pressure, followed by laser or other specialized assistance
Orbital cellulitis	hospitalization, intravenous antibiotics, CT scan
Optic neuritis	neuro-ophthalmological and neurological assessment, high-dose therapy in appropriate cases

The table summarizes data from the international dry eye consensus and clinical reviews on corneal erosions, keratitis, uveitis, scleritis, glaucoma, orbital cellulitis, and optic neuritis.[39]

Special situations: contact lenses, chemical burns, herpes and prevention

Contact lenses are one of the most significant risk factors for severe eye pain. The U.S. Centers for Disease Control and Prevention emphasizes that water and contact lenses do not mix: water can alter the shape of soft lenses, scratch the cornea, and facilitate the entry of microbes. Water contact is particularly dangerous due to Acanthamoeba, which can cause extremely painful and difficult-to-treat keratitis. [40]

Therefore, lenses should be removed before showering, swimming, or using hot tubs. If water does come into contact with the lenses, they should be removed as quickly as possible, and disposable lenses should be discarded. This simple measure can significantly reduce the risk of infection, which then requires months of treatment and, in severe cases, can result in a corneal transplant or blindness. [41]

A chemical eye burn is a situation where first aid begins before a doctor arrives. Both the AAFP and the American Academy of Ophthalmology emphasize that if exposed to a chemical, the eye should be immediately and copiously flushed with a readily available, non-caustic solution, followed by urgent medical attention. Waiting without flushing is more dangerous than choosing an "imperfect" solution. [42]

Ophthalmic herpes zoster also deserves special attention. If eye pain is accompanied by a unilateral vesicular rash on the forehead, upper eyelid, or along the ophthalmic branch of the trigeminal nerve, treatment should be initiated early. The American Academy of Ophthalmology recommends that systemic antiviral medications be initiated within the first 72 hours of the rash's onset, as this reduces pain, accelerates healing of the rash, and reduces the risk of ocular complications. [43]

From a preventative standpoint, the most helpful are simple measures: careful handling of lenses, avoiding contact with water, eye protection during work and repairs, prompt treatment of dry eyes, avoiding self-administration of anesthetic drops, and prompt in-person assessment for pain and vision impairment. Most severe outcomes in this area are not due to the "rarity of the disease," but to late recognition and incorrect initial interventions. [44]

Table 6. What to do and what not to do if you have eye pain

Situation	What to do	What not to do
Pain due to lenses	remove lenses immediately and consult a doctor	Do not continue wearing lenses, do not rinse them with water
Chemical spill	Immediately rinse the eye for 20-30 minutes and go for help	don't wait for it to "go away on its own"
Suspected erosion	examination, fluorescein, gentle mode	do not use local anesthetics at home
Severe pain and areolas	urgent emergency care	don't put it off until tomorrow
Pain when moving the eyes and decreased vision	urgent ophthalmologic or neuro-ophthalmologic evaluation	don't limit yourself to just painkillers
Rash on forehead and eye pain	promptly begin antiviral therapy as prescribed by a doctor	don't waste the first 72 hours
Photophobia and red eye	in-person diagnostics to rule out keratitis and uveitis	do not treat with random "redness drops"

The table is based on data on corneal erosions, contact lenses, chemical burns, herpetic ocular lesions, and clinical evaluation of the diseased eye.[45]

FAQ

Can dry eyes actually hurt, not just feel dry?
Yes. Current international consensus considers dry eye syndrome a multifactorial disorder with inflammatory and neurosensory mechanisms, so pain, burning, and severe discomfort are entirely possible. [46]

If your eye is red and painful, is it always conjunctivitis?
No. Severe pain, photophobia, decreased vision, halos, nausea, pain with eye movement, or lens symptoms make keratitis, uveitis, glaucoma, scleritis, or orbital cellulitis more likely than simple conjunctivitis. [47]

Why are contact lenses so often mentioned in connection with eye pain?
Because they significantly increase the risk of microbial keratitis, and contact with water further increases the risk of severe infections, including Acanthamoeba keratitis. Therefore, a sore eye in a contact lens wearer requires special care. [48]

Is it possible to simply patch the eye or use anesthetic drops?
Patching for typical uncomplicated erosions does not improve outcomes and may slow healing, and local anesthetics for self-administration are toxic to the cornea and mask the deterioration. [49]

When is pain with eye movement particularly dangerous?
When it's combined with decreased vision, color vision impairment, eyelid swelling, fever, limited ocular mobility, or double vision. Then, optic neuritis and orbital cellulitis should be ruled out. [50]

What should you do if a chemical gets into your eye?
Immediately and thoroughly rinse the eye with a readily available, non-caustic solution, without delaying until you reach the hospital, and then seek immediate ophthalmological care. [51]

Is the eye always red with optic neuritis?
No. Pain with eye movement, subacute visual impairment, and color vision disturbances are more typical for optic neuritis, and significant redness may be absent altogether. [52]

When is antiviral treatment for herpes zoster of the eye most effective?
The best effect is expected if treatment is started within the first 72 hours of the rash appearing. [53]

Key points from experts

Anne L. Coleman, MD, PhD, is a professor of ophthalmology at the Jules Stein Eye Institute at the University of California, Los Angeles, and a professor of epidemiology.
Key message: A painful eye with halos, nausea, and blurred vision should be considered a possible acute attack of angle-closure glaucoma until proven otherwise, because with this form of glaucoma, delay directly threatens vision. [54]

Anat Galor, MD, MPH, is an expert in ocular surface pain and dry eye and a professor of clinical ophthalmology at the Bascom Palmer Eye Institute at the University of Miami.
Key message: Dry eye should not be dismissed as a "minor irritation" because it is an ocular surface disorder with a disruption of tear film homeostasis and a neurosensory component, meaning that severe pain associated with it can be clinically real and significant. [55]

Jennifer Rose-Nussbaumer, MD, is a board-certified ophthalmologist and cornea specialist at Stanford University's Byers Eye Institute.
Key message: Any painful, red eye in a contact lens wearer requires a low threshold of suspicion for infectious keratitis, because lenses remain the leading risk factor for microbial corneal disease. [56]

Amanda Henderson, MD, Frank B. Walsh Professor of Neuro-Ophthalmology and Chief of the Division of Neuro-Ophthalmology at the Johns Hopkins Wilmer Institute.
Key message: The combination of pain with eye movement, subacute visual impairment, and color vision disturbances should prompt a diagnosis of optic neuritis, followed by magnetic resonance imaging of the orbits and brain. [57]

John H. Kempen, MD, MPH, PhD, is an expert in inflammatory diseases of the eye, including uveitis and scleritis, Massachusetts Eye and Ear Infirmary, Harvard Medical School.
Key point: Painful, photosensitive red eyes are often not only a local ocular problem but also a possible marker of a systemic inflammatory disease, so a comprehensive approach to uveitis and scleritis includes a thorough assessment of the underlying cause, not just the selection of eye drops. [58]

Conclusion

Eye pain is a symptom with a very wide range of causes: from dry eye and corneal erosion to glaucoma, keratitis, uveitis, scleritis, optic neuritis, and orbital cellulitis. For prognosis, the most important factor is not the severity of the pain itself, but the combination of symptoms: decreased vision, photophobia, halos, nausea, pain with eye movement, fever, contact lenses, chemical exposure, and herpes rash require a particularly rapid route. [59]

The most practical strategy for the patient is simple: don't dismiss severe eye pain as "normal irritation," don't continue wearing lenses if pain and redness occur, don't self-administer topical anesthetics, rinse the eye immediately if chemical exposure occurs, and don't delay an in-person examination if pain is accompanied by vision loss. These simple steps are often the deciding factor in a favorable outcome. [60]