Differential diagnosis of unilateral retro-orbital pain, photophobia

The authors discuss the differential diagnosis and work-up of a 38-year-old woman who presented with chronic left retro-orbital pain and photophobia. The diagnosis of cervicogenic headache was confirmed by symptom resolution following left greater occipital nerve (GON) blockade. They say that ophthalmologists should consider cervicogenic eye pain in the differential diagnosis of unilateral eye pain.

The woman had developed the symptoms a day or two after left optic nerve sheath fenestration (ONSH) for vision loss secondary to neuroretinitis. She experienced the pain for most of every day for 3.5 years after the surgery. She rated the pain that originated in the back of the left eye and radiated outward in all directions as 10 out of 10 and described it as severe, sharp, and stabbing. She denied frontal, temporal, occipital and neck pain.

She regained vision in her left eye six to eight months following ONSF without any change in her pain, which was unresponsive to narcotics, corticosteroids and multiple anticonvulsants. BCVA was 20/20 OD and 20/40 OS.

There was tenderness over the left occipital prominence, and this reproduced the eye pain. Treatment with high-dose oral acetaminophen and ibuprofen did not ameliorate the pain. One week later, she underwent left GON block with 1 mL lidocaine 1% without epinephrine and 1 mL triamcinolone 40 mg/mL. Her pain and photophobia completely resolved within 30 minutes, and she remained pain free at four years follow-up.

The authors say the patient’s eye pain may have been triggered by positioning during ONSF or by postoperative inflammation.