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Eye pain is a worrying symptom, and rightly so. In most cases the cause is relatively simple, such as dryness or inflammation of the eyelid margins. But sometimes eye pain is a sign of a condition that needs urgent treatment. On this page we will help you tell the two apart, understand when dryness is to blame, and what is checked at the clinic.
When to see a doctor straight away: a sudden drop in vision; severe or worsening pain; a red eye with strong sensitivity to light; pain with haloes around lights, headache, nausea or vomiting; pain on moving the eye together with reduced vision; any injury to the eye or chemical getting into it (rinse immediately with running water and go to the emergency department); contact lens wearers with pain and redness (take the lenses out and get seen the same day); a rash with blisters on the forehead or around the eye. In these situations do not wait, and do not treat yourself with drops.
What does the pain feel like? It is an important clue
The way you describe the pain helps the doctor home in on the cause. The following table is only an aid, and does not replace an examination:
| The sensation | Possible causes |
|---|---|
| Burning, grittiness, a foreign-body feeling, worse in front of a screen or at the end of the day | Dry eye, inflammation of the eyelid margins (blepharitis) |
| Sharp pain on opening the eyes in the morning | Recurrent corneal erosion, night-time dryness, eyelids that do not close fully |
| Localised, stabbing pain, tearing, difficulty opening the eye | A foreign body or a scratch on the cornea |
| Deep, dull pain with sensitivity to light and redness around the cornea | Inflammation inside the eye (uveitis) or inflammation of the cornea (keratitis), both of which need an urgent examination |
| Sudden severe pain with blurring, haloes and nausea | An acute attack of glaucoma (a sudden rise in the pressure inside the eye), an emergency |
| Deep, boring pain that wakes you from sleep | Inflammation of the white of the eye (scleritis), sometimes linked to an autoimmune disease |
| Pain around the eye, behind it or in the forehead | Eye strain, sinusitis, migraine or headache |
| Strong pain or burning with no findings on examination | Neuropathic eye pain (oversensitivity of the sensory nerves) |
When dry eye is the cause
The cornea (the clear window at the front of the eye) is very rich in sensory nerves. When the tear film is unstable, the surface of the cornea is exposed to friction and air, tiny defects form in it, and the nerves respond with pain. In addition, tears that are too concentrated trigger inflammation, and the inflammation increases sensitivity.
Dry eye pain tends to be:
- In both eyes, even if one eye is worse.
- Variable during the day, and worse in front of screens, in air conditioning, in wind and on flights.
- Accompanied by burning, mild redness, blurring that improves with blinking, and sometimes, surprisingly, excessive watering.
- Better for a short time after lubricating drops.
If this sounds familiar, read the guide Dry eye: what it is and when you need a specialist, and also the page on burning eyes.
Recurrent corneal erosion
One condition worth knowing about is recurrent corneal erosion. The top layer of the cornea does not attach well, and at night it sticks to the eyelid. When you open your eyes in the morning it tears, and sharp pain, tearing and sensitivity to light appear. This sometimes happens after an old scratch on the cornea, and dryness increases the risk. This condition needs an examination by an eye doctor.
Pain without visible dryness
In some people the pain is strong, but the examination looks almost normal. In such cases the corneal nerves themselves may have become oversensitive, for example after eye surgery, a viral infection or a long period of dryness. This is called neuropathic eye pain. The pain is completely real, and it is important to recognise it, because lubricating drops alone usually do not help it.
Other common causes
- Inflammation of the eyelid margins and the meibomian glands: red eyelids, scales at the base of the lashes and a feeling of heaviness. See blepharitis.
- A stye or chalazion: a painful or tender lump in the eyelid. See stye and chalazion.
- Conjunctivitis (inflammation of the conjunctiva): usually causes discomfort, itching and discharge rather than deep pain.
- Contact lenses: wearing them for long periods, sleeping in them or inadequate hygiene can cause irritation, and also a corneal infection.
- After eye surgery: mild discomfort after surgery is expected, but worsening pain, reduced vision or increasing redness require you to contact the surgeon immediately.
- Eye strain: unsuitable glasses or long periods of close work can cause tiredness and pain around the eyes.
Pain behind the eye: when it is not dryness
Dry eye usually causes pain on the surface of the eye: burning, a gritty or foreign-body feeling, and sensitivity to wind and screens. Deep pain, felt behind the eye or inside the eye socket, is less typical of dryness, and usually has other causes.
Common causes of this kind of pain are inflammation of the sinuses (cavities in the bones of the face around the eyes and nose), migraine and other headaches, and eye strain after long hours of close work, especially without suitable glasses. In these conditions the pain is sometimes accompanied by a blocked nose, pain in the forehead or cheeks, or a headache you already recognise.
There are also less common causes that need an urgent examination, such as inflammation inside the eye or behind it, or a sudden rise in the pressure inside the eye. Eye disease linked to the thyroid gland can cause a feeling of pressure behind the eyes, a bulging eye and double vision, and sometimes dryness too. See dry eye and the thyroid gland.
Pain behind the eye that needs immediate attention: pain on moving the eye together with reduced vision; sudden, severe pain in the eye with headache, nausea, blurred vision or haloes around lights; double vision or an eye that looks more prominent than the other.
One eye or both?
The side on which the pain appears also gives a clue. Dryness, inflammation of the eyelid margins and allergy usually affect both eyes, even if one of them is worse. Pain in one eye only, especially if it came on suddenly, raises suspicion of a foreign body, a scratch, a corneal infection, inflammation inside the eye or a rise in the pressure inside the eye. So new pain on one side warrants a quicker examination.
Timing matters too. Pain that appears at the end of a working day at the computer and disappears at the weekend fits dryness and strain. Pain that wakes you from sleep, or gets worse from day to day, does not fit simple dryness and needs to be investigated.
What does the eye doctor check?
The examination starts with questions: when the pain started, whether it is in one eye or both, whether your vision has changed, whether you wear contact lenses, and which drops and medicines you use. Then the doctor:
- Checks your visual acuity.
- Examines the eye with a slit lamp (a microscope for examining the eye), and puts in a yellow dye (fluorescein) that shows up scratches, defects and dryness on the cornea.
- Checks the stability of the tears (TBUT), and sometimes their quantity with a Schirmer test.
- Checks the eyelid margins, the meibomian glands and the base of the lashes.
- If needed, measures the pressure inside the eye and examines the inner part of the eye.
When the pain is unexplained, a numbing drop is sometimes put in to see whether the pain goes away. The response helps distinguish pain that comes from the surface of the eye from pain that comes from the nerves. Details of the tests are on the dry eye testing page.
What can you do in the meantime?
If there are no warning signs and the pain is mild and familiar to you, you can try simple steps:
- Preservative-free lubricating drops (see preservative-free drops).
- Short breaks from screens, and full, deliberate blinking.
- Directing the air conditioning or fan away from your face.
- Stopping contact lens wear for a while.
- Warm compresses on the eyelids, if there are signs of inflammation of the eyelid margins.
Do not use numbing drops at home, and do not use steroid drops without a prescription and follow-up. Numbing drops harm the healing of the cornea, and steroids can raise the pressure inside the eye and make certain infections worse.
If the pain keeps coming back, lasts more than a few days or does not improve with these steps, it is worth getting examined. When it turns out that dryness or the meibomian glands are behind the pain, there are treatments that address the cause, such as meibomian gland expression, IPL treatment and punctal plugs.
Want a basic explanation first?When to see a doctor about eye symptoms: the guide on the Mitzmutz site
Frequently asked questions
Can dryness cause pain behind the eye?
In most cases, no. Dryness usually causes pain on the surface of the eye, such as burning and a gritty feeling. Deep pain behind the eye more often comes from the sinuses, a headache or eye strain, and sometimes from a condition that needs an urgent examination. If the pain keeps coming back, or comes with a change in vision, it is worth getting examined.
Can dry eye cause real pain?
Yes. Dryness damages the top layer of cells on the cornea, which is one of the most sensitive tissues in the body. The sensation is usually burning, grittiness or a foreign-body feeling, and sometimes real pain.
Why does my eye hurt especially when I wake up?
Dryness at night, eyelids that do not close fully or inflammation of the eyelid margins cause symptoms that are worse in the morning. Sharp pain on opening the eyes can also come from recurrent corneal erosion, and warrants an examination by an eye doctor.
What should I do if my eye hurts but the doctor sees nothing?
Sometimes the pain comes from oversensitive corneal nerves, a condition called neuropathic eye pain. It is completely real, and it has its own treatment approaches.
I wear contact lenses and my eye is painful and red. What should I do?
Take the lenses out straight away and do not put them back in. Pain and redness in contact lens wearers can be a sign of a corneal infection, and you should see an eye doctor the same day.
Home care not enough? We can look into it.
At the dry eye clinic in Haifa we find out what is causing the dryness and build a personal treatment plan.
Sources
- Cronau H, Kankanala RR, Mauger T. Diagnosis and management of red eye in primary care. Am Fam Physician. 2010;81(2):137-144.
- Galor A, Moein HR, Lee C, et al. Neuropathic pain and dry eye. Ocul Surf. 2018;16(1):31-44.
- Craig JP, Nichols KK, Akpek EK, et al. TFOS DEWS II Definition and Classification Report. Ocul Surf. 2017;15(3):276-283.
- Akpek EK, Amescua G, Farid M, et al. Dry Eye Syndrome Preferred Practice Pattern®. Ophthalmology. 2019;126(1):P286-P334.
- Amescua G, Akpek EK, Farid M, et al. Blepharitis Preferred Practice Pattern®. Ophthalmology. 2019;126(1):P56-P93.
The information on this site is general only. It is not medical advice and does not replace an examination by an eye doctor.