Periocular Pain
- Pain in, around, or behind the eye
- Pain arises from activation of nociceptive trigeminal receptors by inflammation, ischemia, or displacement
- Trigeminal nociceptive receptors lie in the periocular skin, ocular adnexal tissue, paranasal sinuses, and all ocular structures except the retina, but also—importantly—in cranial blood vessels and meninges
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Tip: stimulation of any of those trigeminal receptors causes pain that is often referred to the eye
- Ocular surface disorders, acute glaucoma, uveitis, endophthalmitis
- Herpes zoster ophthalmicus
- Orbital inflammation, tumor
- Giant cell arteritis
- Optic neuritis
- Sinusitis, sinus tumor, mucocoele
- Cavernous sinus inflammation, fistula, thrombosis, aneurysm, tumor
- Pituitary apoplexy, pituitary abscess
- Meningitis, subarachnoid hemorrhage
- Migraine
- Trigeminal neuralgia
- Trigeminal autonomic cephalalgia (especially cluster headache)
- Intracranial pressure rapid elevation
- Brain aneurysm
- Brain parenchymal hemorrhage
- Posterior reversible encephalopathy syndrome
- Reversible cerebral vasoconstriction syndrome
- Dural venous sinus thrombosis
- Arterial dissection
- Vasculitis
- Intracranial hypotension
- Tenderness of lids, tearing, ptosis = ocular adnexal or orbital inflammation
- Redness, chemosis of conjunctiva = ocular surface, adnexal, or orbital disorders, carotid-cavernous fistula, cavernous sinus thrombosis
- Foreign body sensation = keratopathy
- Itching = ocular allergy
- Photophobia = keratopathy, uveitis, acute glaucoma, photoreceptor dystrophy, meningeal irritation, migraine
- Tearing = ocular surface disorder, acute glaucoma, uveitis, endophthalmitis, trigeminal autonomic cephalalgia
- Elevated intraocular pressure = acute glaucoma, carotid-cavernous fistula
- Pain worsened by bending over = sinusitis
- Diplopia, ocular ductional deficits = orbital, cavernous, meningeal disorders
- Papilledema = increased intracranial pressure
- Jaw claudication, scalp tenderness = giant cell arteritis
- Ptosis, ipsilateral miosis, unilateral neck or face pain = cervical carotid dissection, parapharyngeal abscess
- Trigger points = trigeminal neuralgia
- Trigeminal dermatomal skin rash = herpes zoster
- Preceding classic visual aura = migraine
- Acute systemic hypertension, use of calcineurin inhibitors, altered mental status, homonymous field loss, seizures = posterior reversible encephalopathy syndrome
- Use of systemic adrenergic agents (including cocaine), post-coital onset = reversible cerebral vasoconstriction syndrome
- Elicit qualifiers of pain: time of onset, duration, character, aggravating and relieving factors
- Inquire after concurrent symptoms
- Look for accompanying signs
- Distinguish between ocular, ocular adnexal, orbital, paranasal sinus, and intracranial causes
- Order orbit and intracranial imaging if you are unable to diagnose an ocular cause; you must do so with an urgency depending on the severity and acuteness of the manifestations