Eye socket pain

Eye socket pain

Eye socket pain is widely interpreted as eye pain or pain in the eye. It is described as the present of sensation of foreign bodies which may be stabbing, aching or throbbing. The exact location and sites as well as duration provide us with the clue regarding the precipitating factors. The pain in the eye is varied from mild to severe.

Glaucoma, neurological disorders, eye disorders, corneal abrasion and systemic disorders are the main causes of eye pain. These disorders will stimulate the external eye and the nerve ending of the cornea to produce pain.

In emergency setting such as during a chemical burn, the patient is advised to remove the contact lens (if it is wear), or spectacles. Then the, eye is irrigated with at least 1 liters of normal saline solution over 10 minutes. The eyelid is everted and the fornices are wiped to remove any chemical or particles using the cotton tip applicator. Acute angle closure glaucoma may cause pain. An immediate action is required to reduce the intra ocular pressure. Surgical peripheral iridectomy or laser iridectomy is required to reduced the intra ocular pressure if the treatment by drug is useless.

Complete history is taken if the pain in the eye is not associated with a chemical burn. The patient is asked regarding the time when it worst (evening or morning), the duration of the pain (how long does it last ), the time when it first noticed, the characteristic of the pain (ache or sharp in nature ), any associated symptoms such as any discharge, itching or burning sensation, any headache, trauma or surgery and the frequency of the pain in the eye.

While performing a physical examination, the conjunctiva and the eyelid are carefully assessed by looking for any swelling, redness or inflammation. Generally, inspect the eye for exophthalmos or ptosis. Extra ocular movement and visual acuity with or without correction is assessed. Any discharged is characterized.

Complete physical examination of the eye begins with examination of the external eye. Inspect the eyelid. Looks for any evidence of incomplete closure or ptosis. Inspect also for any evidence of erythema, edematous, masses, hematoma or cyanosis of the eyelid. Evaluate the skin for any swelling, growth or lesions or tenderness on palpation. Inspect the eye lashes (do the eye lashes turn inward, do the eyelashes contain any discharge, adhere to each other and do some of the eyelashes been lost). Also inspect the eyelid for any everted or inverted sign. Observe and note the present of eyelid spasm, or any lesions, scaling, debris or unusual secretions from the lid margin. The forefinger and thumb are used to retract the eyelid gently and assess the conjunctiva for blisters, follicles, cloudiness and redness. Sclera is inspected and notice any change in the color from normal (white). Chemosis is checked by compressing the lower eyelid against the eyeball and observed any bulging at a point above the compression sites.

Then, a light is shone at the cornea. Look for any evidence of abrasion or ulceration of the corneal. Any cloudy areas, opaque, dots, or discharged are inspected. Next, assess the anterior chamber of the eye. The normal anterior chamber of the eye should be clean, shadow clears, deep and filled with aqueous humor that is clear. After that inspect, the texture, pattern, shape and color of the iris. Assess the shape , sizes and equality of the pupil. Assess the response of the pupil to the light. The response of the pupil may be normal, unresponsive or sluggish. Finally, dilation or constriction of the pupil should also be noted. (Does the constriction or dilation of the pupil occurs on one side).

The differential diagnosis of eye socket pain/eye pain are conjunctivitis, chalazion, burns, blepharitis, acute angle closure glaucoma, foreign bodies in the conjunctiva or cornea, erythema multiforme major, episcleritis, dacrocystitis, corneal ulcer, corneal abrasion, subdural hematoma, sclerokeratitis, scleritis, optic neuritis, ocular laceration and intraocular foreign bodies, migraine headache, lacrimal gland tumor, iritis (acute), stye (hordeolum), uveitis and trachoma.

There are 4 different types of conjunctivitis. Bacteria conjunctivitis produces conjunctival secretion , injection, purulent discharge, foreign body sensation and burning. Bacterial conjunctivitis may cause pain if cornea is affected. Viral conjunctivitis produces edematous eyelid, follicles of the conjunctival (visible), foreign body sensation and itchy red eyes. Allergic conjunctivitis, produce bilateral mild burning pain accompanied by ropey discharge, conjunctival injection and itching. Fungal conjunctivitis, will cause photophobia and pain if cornea is affected. Without cornea involvement it may present with thick purulent discharge, burning eyes, itching and injection of the conjunctival.

Chalazion is a small red lump that is presented with conjunctival injection when the eyelid is everted. Chalazion causes swelling and localized tenderness of the lower and upper eyelids.

A burn may include UV radiation burn and chemical burn.UV radiation burn is presented with moderate to severe pain last for 12 hours and changed in the vision as well as photophobia. The chemical burn is presented with severe and sudden pain with blurring of the vision, miosis, photophobia, inability to keep an open eye and blistering as well as erythema of the eyelid and faces.

Blepharitis is presented with pain in the eyelid that is burning in characteristic and sticky discharge, itching and conjunctival injection. Other findings are loss of eyelashes, ulceration of the eyelid and foreign bodies sensation.

Acute angle closure glaucoma is presented with excruciating pain that is sudden in onset. The excruciating pain is accompanied by abdominal pain, nausea and vomiting. On examination, there will be a decrease in visual acuity, halo vision, fixed, moderately dilated or non reactive pupil.

The present of foreign bodies in the cornea or conjunctiva is typically present with dark speck on the cornea, excessive tearing, sensation of foreign bodies, photophobia, sudden severe pain and injection of the conjunctival.

Erythema multiforme major is presented with decrease in the formation of the tear, photophobia, purulent conjunctivitis, itchiness, entropion and severe eye socket pain.

Episcleritis is associated with inflammation of the tissue over the sclera. It is presented with severe deep pain in the eye, purplish or red sclera, conjunctival edema, excessive tearing and photophobia.

Dacryocystitis is associated with tenderness and pain near the tear sac. Other signs are swelling in the lacrimal punctum area, erythematous eyelid, purulent discharge and excessive tearing.
There are 2 forms of corneal ulcer which is fungal corneal ulcer and bacterial corneal ulcer. Fungal corneal ulcer produces severe eye pain, eyelid erythema and edema, conjunctival injection and clearer rings progressively surrounding the dense cloudy cornea. Bacterial corneal ulcer also produces severe eye pain, sticky eyelid, photophobia, purulent eye discharge, impaired visual acuity and conjunctival injection, unilateral pupil constriction, and grayish white irregular ulcer.

The signs and symptoms of corneal abrasion are conjunctival injection, photophobia, excessive tearing and foreign body sensation.

After a trauma to the head, subdural hematoma may develop. Subdural hematoma may cause severe headache and eye ache. The sizes and the location of hematoma determine the neurological signs.

Inflammation of the cornea and sclera is known as sclerokeratitis. Sclerokeratitis is presented with photophobia, irritation, pain and burning. Inflammation of the sclera is called scleritis and present with bluish purple sclera, severe eye pain, excessive tearing,photophobia, conjunctival injection and tenderness as well as severe eye pain.

In optic neuritis, the pupil responds normally to consensual light but direct light respond is sluggish. Tunnel vision and severe loss of vision will improve in 2-3 weeks and pain is severe in nature and with eye movement.

Penetrating eye injuries may cause laceration of the ocular surface and intraocular foreign bodies. The trauma may cause unilateral eye pain (mild to severe) , conjunctival injection, impaired visual acuity, abnormal response of the pupil and eyelid edema.

Noise and light sensitivity are associated with migraine headache. Besides that migraine headache is associated with blurred vision, vomiting, nausea and eye pain.

A neoplastic lesion, such as lacrimal gland tumor may produce some degrees of exophthalmos, impaired visual acuity and unilateral eye pain.

Acute iritis is an acute inflammation of the iris and presented with blurred vision, conjunctival injection, severe photophobia, severe eye pain and poorly reacted to light (the constricted pupil). Stye or hordeolum is associated with edema and eyelid erythema. It may cause localized eye pain as the stye grow.

There are 3 different forms of uveitis such as anterior uveitis; posterior uveitis and lens induced uveitis. Anterior uveitis present with non reactive small pupils, photophobia, conjunctival injection and sudden onset of severe pain. Posterior uveitis produces a similar symptom with distortion in the shape of the pupil and gradual blurring of the vision. The patient with lens induced uveitis can perceived only light. The lens induced uveitis cause a severely impaired visual acuity, constriction of the pupil, conjunctival injection and moderate eye pain.

Ocular surgery may cause eye socket pain from mild pain /tenderness to stabbing sensation. Contact lens also may cause foreign body sensation and eye pain.

Patient with eye socket pain is advised to lie down and closed his eyes in a quiet and dark environment. Orbital X ray and tonometry are useful to investigate the cause.

Infection and trauma are the most common cause of eye socket pain in children. Observe for any non verbal clues such as constantly rubbing the eyes or frequently shut the eyes as tightly as possible.

Glaucoma is significantly affecting people age 40 years and above. It is a disease of older people. Glaucoma is bilateral in nature and progressively may lead to loss of peripheral visual field.

chalazion | Source
swelling of the optic disc in optic neuritis
swelling of the optic disc in optic neuritis | Source
trachoma | Source

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