This document discusses various causes of periocular pain and eye pain, including primary and secondary headache syndromes, ocular diseases, orbital diseases, vascular diseases, and intracranial diseases. It emphasizes taking a thorough history and performing an examination of the eyes, vision, pupils, and cranial nerves. Specific conditions mentioned that can cause periocular or eye pain include migraine, cluster headache, tension headache, chronic daily headache, dry eye, uveitis, glaucoma, giant cell arteritis, carotid artery disease, and increased intracranial pressure. The document provides guidance on evaluating and treating some of these conditions.

1. Raed Behbehani , MD FRCSC

2. •Periocular pain due to diseases of the face, orbit, sinuses , and
intracranial cavity.
•Trigeminal innervation (V1-V3).
•Primary headache syndrome vs Secondary headache syndrome

3. • Any headache can cause eye pain (vice versa).
• Take good history ( loss of vision, diplopia, redness, photophobia,
jaw claudication, systemic symptoms).
• Examination : check vision at least grossly, look for redness, ptosis,
corneal edema, check pupil reactions, palpate the eyes and orbits,
check sensation v1-v3 and other cranial nerves.
•FUNDOSCOPY !

4. • Migraine (with / without aura)
•Cluster Headache .
•Tension Headache.
•Chronic Daily Headache.
•Medication overuse.

5. • Ocular disease.
• Orbital disease.
• Vascular disease.
• Intracranial disease .

7. • Inadequate tear production.
• Primary / Secondary to rheumatological conditions.
• Slit lamp examination : Flourescin stain/ Rose bengal
• Artificial tears/ punctal occlusion is the treatment.

9. • Anterior/Posterior Uveitis.
•Pain and Photophobia.
• Cells in the anterior chamber/ Ciliary injection/ Posterior
synechiae.
• Idiopathic/ associated with rheumatologic conditions/ infectious
(post-operative).
• Topical steroids for anterior / periocular and systemic for posterior
• Intravitreal antibiotics for infectious post-operative.

11. • Severe periocular pain +- headache.
• Blurred vision , nausea , and vomiting.
• Cilliary injection/ corneal edema/ fixed mid-dilated pupil.
• Previous history of transient visual disturbances .
• Laser iridotomy.

13. • New onset of headache (temporal) , acute or transient loss of vision,
jaw claudication, weight loss, fever, and myalgias.
• Age over 60.
• Anterior/posterior ischemic optic neuropathy
• Retinal artery occlusion.
• ESR, CRP, CBC.
• Systemic steroids ( oral or IV).
• Temporal artery biopsy.

14. .
• Deep boring pain in the eye upon standing up or with sustained
exposure to light (ocular claudication) .
•Impaired retinal cicrulation due stenosis of the aoortic
arch/carotids.
• Fundus examination shows sign of ischemia (dilated retinal veins,
hemorrhages, cotton wool spots, neovascularization).
• ? Carotid endarterectomy.

16. • Incorrect glasses/ contact lenses.
• Uncorrected presbyopia.

17. • Optic neuritis.
• Orbital inflammtory disease.
• Orbital mass.
• Orbital vascular malformation.

18. • Sudden onset.
•Pain, proptosis, limited eye movement, chemosis.
• Idiopathic or due to Wegener’s granulmatosis, Grave s’ disease,
sarcoidosis)

21. • Can be primary (pseudo-tumor cerebri) or secondary (mass,
hemorrhage)
• Headache, pain in the neck and shoulders and upper back.
•Worse with coughing/straining.
•Pulsatile tinnitis.
•Transient visual obscurations.
• Diplopia.
• Treatment of pseudotumor cerebri is Medical ( Diamox ) or Surgical
(Optic nerve sheath fenstration, V-P or V-A shunt).

23. • Take good history ( try to distinguish primary from secondary
headache syndrome).
• Look for abnormal neuro-ophthalmic signs ( Ptosis,
ophthalmoplegia, abnormal facial sensation, check visual acuity,
and pupils, and look for papilledema).
• Giant cell arteritis is vision-threatening.
• Papilledema ican be life threatening.