Painful eye — differential diagnosis (optometry)
Structured for Australian optometry practice.
Clinical decision support only
OptoGuide™ supports professional judgement and does not diagnose or replace clinician responsibility.
Quick answer
- Separate surface irritation from corneal, inflammatory, pressure-related, or traumatic causes early.
- Keratitis, anterior uveitis, scleritis, acute glaucoma, and trauma should be distinguished from milder surface disease.
- Pain with photophobia, reduced vision, corneal staining, or ciliary injection raises urgency.
- Escalate same day when pain is disproportionate, the cornea is involved, or vision is affected.
Common causes
- Dry eye or significant surface irritation.
- Corneal abrasion or keratitis.
- Anterior uveitis.
- Scleritis or severe episcleral inflammation.
- Acute angle closure or traumatic injury.
Red flags (must not miss)
- Marked photophobia or reduced visual acuity.
- Corneal infiltrate, epithelial defect, or opacity.
- Ciliary flush, cells and flare, or irregular pupil.
- Severe unilateral pain with nausea or corneal oedema.
- History of trauma, chemical exposure, or contact lens wear.
Use OptoGuide™ to guide this decision during consult.
What to check
- Pain severity, onset, and whether the pain is surface or deep.
- Visual acuity and pupil responses.
- Fluorescein staining and corneal clarity.
- Pattern of redness and anterior chamber reaction.
- IOP where safe and clinically relevant.
When to refer
- Same day for suspected keratitis, uveitis, acute glaucoma, scleritis, or trauma.
- Urgent review when pain is severe and the diagnosis is uncertain.
- Routine management only when examination supports a clearly benign surface cause.
Initial management
- Localise the pain source: lid, conjunctiva, cornea, anterior chamber, or pressure-related.
- Document acuity, staining, pupil findings, and photophobia clearly.
- Escalate early when pain and signs are out of proportion to a simple surface explanation.
Clinical basis
This guidance reflects standard optometric clinical reasoning based on:
- Australian optometry clinical practice patterns
- Australian medicines regulation and PBS prescribing context
- Common ophthalmology referral standards
- Evidence-based clinical training and practice
Use OptoGuide™ during consult for structured clinical guidance.