Pain upon ocular movement

Specialty: Ophthalmology.

• retrobulbar pain when moving the eyes
• eye pain with saccades
• kinetic ophthalmalgia

Why it occurs

• Previous or retrobulbar optic neuritis (inflammation of the optic nerve where pain is induced by direct traction of the tendons of the superior and medial rectus muscles on the inflamed nerve sheath)
• Orbital myositis (idiopathic localized inflammation of one or more extraocular muscles)
• Deep bacterial orbital cellulitis
• Posterior scleritis or active deep episcleritis
• Ethmoid or sphenoid sinusitis with surrounding periorbital inflammation

Initial workup

Detailed evaluation of visual acuity, pupillary reflexes (DPAR search) and color discrimination (to evaluate the functional integrity of the optic nerve); Quantitative examination of extrinsic ocular motility; Computed Tomography (CT) of the orbits and paranasal sinuses with intravenous contrast (or Magnetic Resonance with STIR sequences of fat suppression and gadolinium, ideal for visualizing inflammation of the optic nerve and extraocular muscles); Blood analysis with erythrocyte sedimentation rate (ESR) and C-Reactive Protein (CRP).

Standard management

• Methylprednisolone — 1 g intravenous daily in single doses for 3 days if associated with demyelinating optic neuritis confirmed by MRI
• Ibuprofen — 600 mg orally every 8 hours, or indomethacin 25 mg orally every 8 hours, used as a first-line non-steroidal anti-inflammatory drug in orbital myositis or posterior episcleritis
• Ceftriaxone (2 g intravenously every 24 hours associated with metronidazole 500 mg intravenously every 8 hours in suspected bacterial orbital cellulitis).