Authored by Nicholas Oliver Corey Kuzik
Reviewed by Stephen Carrell, PGY-4 at University of Alberta
Edited and posted by Yosra Er-reguyeg
July 31, 2026 | 5 min
Part 4: Eye Pain and Photophobia in a Quiet Eye
Pain is subjective and broad. Which is not overly helpful when trying to narrow down the source of a patient’s eye pain. One study found eye pain in 70% (n=1,801) of patients presenting to ophthalmology or neurology was caused by inflammatory eye disease (i.e., conjunctivitis, blepharitis, keratitis, uveitis, dry eye, chalazion, and scleritis).1 More specifically, the top 3 presenting categories for the ophthalmology patients alone were conjunctivitis/keratitis/infection (38%), dry eye/blepharitis (19%), and uveitis (6%).1
Sufficiently narrowed? Should we end the blog here then? No, that level of effort will get zero high fives or fist bumps on your rotation. To narrow it down further we could differentiate between painful red eyes and painful quiet eyes.
Painful red eyes were covered in the last post, so we won’t spend too much time on it. But keratitis, uveitis, acute angle closure, scleritis, endophthalmitis, trauma, and chemical injury (unless severely blanched) should already be on your radar when the eye is visibly angry.
This post focuses on the more confusing patient: someone with eye pain or photophobia but little obvious redness.
Your job is to answer four questions:
First: What Does “Eye Pain” Mean?
Patients may use “eye pain” to describe:
These descriptions are useful, but they overlap.
Burning and grittiness often suggest dry eye, blepharitis or another ocular surface problem. Foreign-body sensation should push you toward fluorescein and lid eversion. Pain with eye movement raises concern for the optic nerve or orbit.
Use the description to guide your next question. Do not let it make the diagnosis for you.
Photophobia is a Symptom, Not a Diagnosis
Photophobia usually means that light causes or worsens discomfort.
It can occur with:
In a unilateral red eye, photophobia should push keratitis and uveitis higher on your differential.
In a quiet-looking eye, broaden your thinking to migraine, dry eye, optic neuritis and other neurologic causes.
The First Branch: Is Vision Affected?
Pain with reduced vision is much more concerning than pain with normal vision.
If visual acuity, colour vision, or the visual field is abnormal, think beyond dry eye and headache.
Important possibilities include:
Optic Neuritis
The classic pattern is:
A useful question is:
“Does red look equally red in both eyes?” - You can test this with the red caps of the dilating bottles.
The optic disc may look normal because inflammation can occur behind the visible portion of the nerve. In fact, ⅔ of optic neuritis are retrobulbar.
Pain with eye movement alone is not enough to diagnose optic neuritis. The diagnosis becomes more likely when pain is accompanied by reduced vision, colour desaturation, or a RAPD.
Pain With Eye Movement: Optic Nerve or Orbit?
Pain with eye movement can also occur with:
Use the accompanying findings to separate them.
More suggestive of optic neuritis
More suggestive of orbital disease
The useful question is not just:
“Does moving the eye hurt?”
It is:
“What else happens when the eye moves?”
Do Not Forget Giant Cell Arteritis
In a patient over 50 with “pain” (usually headache) or visual symptoms, ask about:
Do not assume optic nerve dysfunction in an older patient is routine demyelinating optic neuritis.
Giant cell arteritis can permanently affect vision or continue to the other eye and needs immediate escalation.
When Headache Is the Main Feature
The eye and several intracranial structures share sensory pathways. That means migraine, raised intracranial pressure, and vascular disease can all be experienced as pain in or behind the eye.
Migraine
Features may include:
Migraine is common, but it should not become a shortcut diagnosis.
Before calling it migraine, check:
A normal examination and a typical recurrent headache pattern make migraine more likely.
Cluster headache
Think about cluster headache when there is:
Raised intracranial pressure
Possible clues include:
These symptoms should prompt a careful fundus examination for papilledema.
Headache Red Flags
Stop and escalate when eye pain or photophobia is accompanied by:
A painful Horner syndrome can occur with carotid artery dissection. A painful third nerve palsy may indicate a compressive aneurysm.
These are uncommon, but missing them matters. Urgent imaging is warranted when suspecting these above entities.
What If Vision Is Normal?
Normal visual acuity is reassuring, but it does not end the assessment.
Dry eye and blepharitis
Look for:
Excessive tearing does not rule out dry eye. Surface dryness can cause reflex tearing. Conduct a thorough slit-lamp exam and assess tear break-up time (TBUT). These steps will help identify blepharitis (collarettes) and dry eye (<10 seconds TBUT, punctate epithelial erosions on fluorescein).
Corneal abrasion or foreign body
A small abrasion or retained foreign body may cause severe pain with little initial redness.
Ask about:
Use fluorescein and evert the upper lid. The eyelid can hide the problem while everyone wonders why the patient still hurts.
Corneal neuropathic pain
Some patients have severe pain or photophobia that seems disproportionate to visible findings. This can occur after dry eye, infection, surgery, or injury to the corneal nerves. You are unlikely to diagnose this independently as a medical student. The important lesson is that persistent pain with a quiet-looking eye should not automatically be dismissed.
The Examination You Need
Start with:
Vision
Check each eye separately. Use correction and just get in the habit of using pinhole.
Compare colour vision between the eyes. Reduced colour vision may be more obvious than reduced acuity in optic neuropathy.
Check EOM for range of movement, pain with movement, and diplopia. Confrontational fields should be equal and unimpeded! While you’re at it check the orbit for proptosis, lid swelling, and ptosis.
Pupils
Assess:
A RAPD suggests asymmetric retinal or optic nerve dysfunction.
Pressure
Measure IOP if there is no concern for open globe. Do not assume a quiet eye has normal pressure, especially when there are halos, nausea, a poorly reactive pupil, or corneal haze.
Cornea & External Eye
Even if the eye looks white, examine:
Fundus
Look for:
A normal disc does not exclude retrobulbar optic neuritis, as disc abnormalities may manifest after visual symptoms.
If You Remember Nothing Else
Most common cause of pain in quiet eyes:
Most alarming cause of pain in quiet eyes:
Could this threaten vision or life even though the eye does not look dramatic?
A quiet eye can be reassuring, but it should not make you careless.
Next month: Flashes and Floaters on Your Ophthalmology Elective
1. Bowen RC, Koeppel JN, Christensen CD, Snow KB, Ma J, Katz BJ, et al. The most common causes of eye pain at 2 tertiary ophthalmology and neurology clinics. Journal of Neuro-Ophthalmology. 2018;38(3):320-7.
