Approach to Eye Pain: Differential Diagnosis and Work Up for the Neurologist

Eye pain is a common but diagnostically complex symptom. The underlying etiologies span neurologic, ophthalmologic, and systemic conditions that range from benign to vision- or life-threatening. This review aims to provide a neurologist-oriented approach to the differential diagnosis of eye pain, emphasizing clinical reasoning and red flag identification.

Ocular inflammation and surface disorders are commonly diagnosed etiologies for eye pain but neurologic disorders including primary headaches may be underrecognized sources of eye pain. Clinical clues like the pain description and location, patterns of visual disturbances, and other associated symptoms can guide diagnosis. Exam clues like optic disc edema, cranial nerve abnormalities, red eye pattern, ocular bruit, and intraocular pressure can guide localization and referral urgency. Integration of targeted history, key physical exam findings, and judicious use of investigations are critical for identifying vision- or life-threatening pathology. Using a focused history with targeted neurologic and ophthalmologic examinations, neurologists will be able to choose appropriate investigations and identify when urgent ophthalmology referral is required. This review outlines a systematic, symptom-based approach to eye pain so that neurologists can identify urgent conditions, improve diagnostic efficiency, and collaborate effectively with ophthalmology.