Pain behind the eye: the common causes, and the signs that make it urgent

Pain behind the eye most often comes from the head rather than the eye: a sinus infection, a migraine or tired eyes. A smaller group of causes is more serious, and they travel with warning signs such as lost vision, a red eye, vomiting or a sudden severe headache. This article sorts the two, explains what an eye doctor checks, and says where to go in an emergency.

What most often causes pain behind the eye?

Usually a headache disorder, a sinus problem or eye strain. The NHS lists eyesight problems among the common causes of headache, alongside colds, stress, poor posture, skipped meals and dehydration, and most headaches go away on their own.

Sinusitis, swelling of the sinuses, is one of the commonest reasons for pressure around the eyes. The NHS describes pain, swelling and tenderness around the cheeks, eyes or forehead, with a blocked or runny nose, a reduced sense of smell and sometimes a high temperature. It usually clears within four weeks. Migraine causes a throbbing headache, often on one side, with nausea and sensitivity to light and sound. Cluster headache is rarer: a sharp, burning or piercing pain, usually on one side around the eye, lasting 15 minutes to 3 hours, often with a red, watering eye and a drooping lid on the same side.

Uncorrected glasses, long hours on a screen and tired eyes can also give a dull ache in and around the eyes. This is the group where nothing is wrong with the eye itself, and a sight test often settles it. Because migraine, cluster headache and glaucoma are managed by other specialists, an eye doctor or a doctor in the emergency department is the right person to assess them, not an oculoplastic surgeon.

Which eye-socket problems cause pain behind the eye?

Three conditions in the orbit, the bony socket that holds the eye, fat and muscles, can hurt from behind: thyroid eye disease, orbital inflammation and orbital cellulitis. These are the conditions an oculoplastic surgeon is trained to assess.

EyeWiki, the American Academy of Ophthalmology's clinical wiki, notes that in more advanced thyroid eye disease people may have orbital pain, double vision or blurred vision. It also scores disease activity on pain, redness, swelling and impaired function, and it calls compressive optic neuropathy, a squeezed optic nerve, an ocular emergency. The signs and the treatment ladder are in my guide to thyroid eye disease, and the wider map of the socket is in orbital conditions explained.

Orbital inflammation can also hurt, sometimes with a swollen upper lid at the outer corner where the tear gland sits; that article explains how it is told apart from an infection.

Orbital cellulitis is an infection of the tissues behind the eyelid's septum, and it is urgent. EyeWiki lists pain with eye movements, a bulging eye, swelling of the white of the eye, limited eye movement, optic nerve involvement and fever as signs that the infection is in the socket, and says an abscess complicates close to 10% of cases. The article on orbital cellulitis and abscess covers when surgery is needed, and the one on a suddenly swollen eyelid helps with the lid-only version.

Why does it hurt when I move my eye, and my vision is blurred?

That pairing points to optic neuritis, swelling of the optic nerve, which needs an eye doctor promptly. The American Academy of Ophthalmology lists blurry or dim vision, dull and faded colours, pain in the back of the eye socket and pain when moving the eyes, in one or both eyes.

Symptoms can arrive suddenly or over a few days, and can be worse when you are hot or very tired, for example after exercise or a hot bath. The Academy names autoimmune disease, including multiple sclerosis, and viral infections among the causes. Steroids help many people, and the Academy stresses that seeing an ophthalmologist matters because treatment can stop symptoms worsening. Pain with eye movement is also a feature of orbital cellulitis and thyroid eye disease, which is one reason the eye examination matters more than guessing from the symptom.

Which signs of pain behind the eye are urgent?

Sudden severe pain with a red eye, rainbow-coloured circles around lights, blurred vision, nausea or vomiting needs an emergency department straight away. The NHS calls this pattern of sudden glaucoma a medical emergency that may need immediate treatment.

Doctors often call the sudden form acute angle-closure glaucoma: the fluid inside the eye cannot drain and the pressure rises quickly, damaging the optic nerve. The NHS lists intense eye pain, a red eye, tenderness around the eyes, halos, blurred vision, feeling sick or being sick, and headache. It notes a higher risk over the age of 50, with a close relative with glaucoma, in people of Asian background and in people with long-sightedness, so this applies to many Malaysian families.

The second urgent pattern is giant cell arteritis, also called temporal arteritis: inflamed arteries at the temples. The NHS lists frequent severe headaches, pain or tenderness at the temples or scalp, jaw pain while eating or talking, and double vision or loss of vision in one or both eyes. It says untreated it can lead to stroke and blindness, that steroids are started before the diagnosis is confirmed, and that anyone with vision problems should see an eye specialist the same day. It mainly affects older adults.

The third is a sudden, extremely painful headache, which the NHS lists as a reason to call emergency services, along with loss of vision, weakness or numbness, confusion, a seizure, a stiff neck with fever or a recent head injury. A headache with vision or eye problems is, at the least, a reason for urgent medical review.

What does a doctor check for pain behind the eye?

The questions and the examination are the same whichever specialist you see: how the pain started, where it sits, what makes it worse, and what else changes. Vision, side vision, colour vision, the pupils, the way the eyes move and the pressure inside the eye are all tested.

For optic neuritis, the Academy describes looking inside the eye with an ophthalmoscope to see whether the optic nerve is swollen, testing side vision and colour vision and checking how the pupils respond to light, with a CT or MRI scan, or a visual brain wave recording, in some people. For a suspected orbital problem, a surgeon also looks at eyelid position, how far the eye protrudes, whether it moves fully and whether it is tender to touch, and a scan of the orbit often follows. For giant cell arteritis, the NHS describes blood tests, then ultrasound of the temples or a small biopsy of the temporal artery.

Where do I go in Malaysia for sudden eye pain?

Go to the nearest hospital emergency department, or call 999 (112 from a mobile phone), if the pain is sudden and severe, if vision is lost or blurred, or if the eye is red with vomiting or halos. Ask someone to drive you, as the NHS advises, because eye pain with blurred vision makes driving unsafe.

For a milder ache with no warning signs, a sight test and a doctor's review are the sensible first step. If a sinus infection has not improved after a week of treatment, the NHS advises seeing a GP. If the lid is swollen, the eye bulges or the eyes look different, an oculoplastic assessment is appropriate; when the cause could be a sinus, a headache disorder or glaucoma, an eye doctor, a neurologist or the emergency department will lead. More on the area is in the orbit and thyroid eye disease section and my hub article on why eyes look tired.