Key Points
Question
How many estimated outpatient and emergency department visits occurred annually in the US for eye pain from 2008 to 2019?
Findings
In this cross-sectional analysis of population-based survey data from 2008 to 2019, there were 4.6 million outpatient and 1.0 million ED visits annually. The largest percentage of outpatient visits occurred with ophthalmologists, and most diagnoses were non–vision threatening.
Meaning
Findings of this study suggest that eye pain was a common reason for visits, diagnoses were often non–vision threatening, and targeted eye pain treatments will be important to reduce the burden on the health care system and to optimize patient outcomes.
Abstract
Importance
National estimates regarding the frequency of presentations and patterns of care for eye pain are unknown. This information could guide research and clinical efforts to optimize outcomes.
Objective
To estimate eye pain visits in the US in the outpatient and emergency department (ED) settings.
Design, Setting, and Participants
This retrospective cross-sectional study of National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey data (2008-2019) analyzed a population-based sample of visits to outpatient clinics and EDs. The sample consisted of patients presenting with eye pain. Data were analyzed from September 2023 to April 2024.
Main Outcomes and Measures
Weighted sample data estimated outpatient and ED eye pain presentations including patient and clinician characteristics, diagnoses (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision [ICD-10]), and disposition.
Results
From 2008 through 2019, 4.6 million (95% CI, 3.9 million to 5.3 million) outpatient and 1.0 million (95% CI, 0.8 million to 1.1 million) ED eye pain visits occurred annually. Patients were predominantly women (63.2% [95% CI, 59.4%-67.0%]) and older than 60 years (46.6% [95% CI, 42.4%-51.0%]) in the outpatient setting. Patients presenting to the ED were more often men (51.8% [95% CI, 48.7%-55.0%]) and aged younger than 45 years (aged <15 years: 16.4% [95% CI, 13.9%-18.8%]; 15-24 years: 19.2% [95% CI, 16.6%-21.7%]; and 25-44 years: 35.6% [95% CI, 32.7%-38.5%]). In nearly half of outpatient eye pain visits, the major problem was classified as nonacute (2.0 million [95% CI, 1.6 million to 2.3 million]). Eye pain was the primary reason for the visit (RFV) in 42.0% (95% CI, 37.8%-46.2%) of outpatient visits and 66.9% (95% CI, 62.9%-70.9%) of ED eye pain visits. It was the only RFV in 18.3% (95% CI, 15.0%-21.7%) of outpatient and 32.7% (95% CI, 29.0%-36.4%) of ED eye pain encounters. Ophthalmologists evaluated the largest number of outpatient visits (45.3% [95% CI, 38.8%-51.7%). The primary diagnosis was non–vision threatening for most outpatient (78.5% [95% CI, 56.8%-100%]) and ED (69.9% [95% CI, 62.1%-77.7%]) visits when eye pain was the primary RFV. Additional follow-up was scheduled in 89.4% (95% CI, 86.2%-92.6%) of visits.
Conclusions and Relevance
More than 5 million eye pain visits occur annually; the largest percentage are outpatient with ophthalmologists. Most diagnoses were non–vision threatening in both the outpatient and ED setting and resulted in additional care. Expanding therapeutic approaches to treat the causes of eye pain may reduce the burden on the health care system and optimize outcomes.
This cross-sectional study estimates the frequency of eye pain visits over time in emergency department and outpatient settings.
Introduction
Eye pain is characterized by symptoms of eye burning, aching, and irritation associated with numerous ophthalmic (eg, dry eye disease, uveitis, infection), neurologic (eg, migraine), and systemic (eg, fibromyalgia) conditions. Patients with eye pain experience decreased quality of life similar to those with an immobilizing hip fracture or moderate or severe angina,1 decreased visual functioning,2 and higher odds of suicidal ideation3 compared with patients without eye pain. However, little information exists regarding the frequency of eye pain visits and patterns of care for patients experiencing this disabling symptom. Prior research studies4,5,6 have focused only on specific diagnoses (eg, dry eye disease) causing eye pain.
Our aim is to ascertain information from nationally representative data regarding the presentation of eye pain in both the outpatient and emergency department (ED) settings across the US. Specifically, we sought to determine the frequency of eye pain visits over time in these settings, as well as describe clinician characteristics, common diagnoses, and visit disposition. This information may help guide future research efforts as well as to help improve care for patients with eye pain.
Methods
Per the Common Rule (45 CFR §46), this study was exempt from review by the University of Michigan Institutional Review Board as data are publicly available. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
Data Sources
We performed an analysis of deidentified cross-sectional data collected for the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) over a 10-year period from 2008 to 2019,7 excluding 2017 because data were not released due to issues processing that year of data during the COVID-19 pandemic.8 We used 10 years of data to maximize the accuracy and precision of the estimates. Data were analyzed from September 2023 to April 2024.
In brief, both NAMCS and NHAMCS are annual nationally representative surveys conducted in the US by the National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention. Both use a multistage probability sampling design of primary sampling units within geographic regions. The basic sampling unit for NAMCS is the patient visit to office-based physicians. Only visits to physicians within the American Medical Association or American Osteopathic Association are included. Notably, optometrists are not included. For NHAMCS, the basic sampling unit is the patient visit to emergency service locations from selected regional hospitals. Only nonfederal, general, and short-stay hospitals in the US with ED were included.
Data Collection Procedures
Visit characteristics were captured using the patient record forms, which then underwent extensive data processing and quality checks. Data elements available in the datasets include patient demographic characteristics, reasons for visit, diagnoses, physician specialty, and recommended follow-up.
Study Sample
Visits for eye pain were identified by using the variable patient’s reason for visit (RFV; eye pain RFV code 13201). Each visit was allowed up to 3 (2008-2013) to 5 (2014-2019) RFVs depending on the survey year. The first RFV listed is identified as the patient’s chief concern. Visits were included if there was an RFV of eye pain in any of the RFV fields.
Selected Variables
We assessed patient characteristics, including age categories (grouped as aged <15 years, 15-24 years, 25-44 years, 45-64 years, 65-74 years, and ≥75 years) determined by NCHS, sex, imputed race, and imputed ethnicity (Hispanic, Not Hispanic). The imputed race variable categorized patients as White, Black, or other (including American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, or more than 1 race reported). The NCHS collects race and ethnicity data to help explain interrelated trends in the health data as well as to examine health status and access to care. Race and ethnicity were imputed by NCHS for each survey to account for missing data.
Additionally, we assessed the acuity of the visit type, resulting diagnoses, and visit disposition. The visit acuity is specified in the patient record forms as relating to the major problem and classified as acute (less than 3 months) or nonacute for the purposes of this study. Nonacute visit types included flare-up or follow-up for a chronic problem, pre- or postsurgical visits, and preventive visits. To determine the diagnoses that resulted from each visit, we used the most recent 3 years of data using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes (2016, 2018, 2019) as ICD-10 was implemented in October 2015. Five diagnoses were recorded for each visit with the first diagnosis identified by the clinician as the primary diagnosis. Diagnoses were further grouped into non–vision-threatening potential causes of eye pain, potentially vision-threatening causes of eye pain, potentially systemic or neurologic (eg, migraine) causes of eye pain, and diagnoses not clearly associated with eye pain (eTable 1 in Supplement 1). Visit disposition was classified as follow-up (return visits within 1 week to 2 months, referral to the ED, or referral to another physician) or no follow-up recommended. Physician characteristics included specialty and geographic region for the physician or hospital location (2018 and 2019 geographic region data unavailable).
Statistical Analysis
Analyses were performed using the svydesign function in the R statistical software package survey, version 4.3.2 (R Foundation for Statistical Computing). Survey data were analyzed using the prespecified sampling weights and weighting procedures to account for the complex study design and sampling. These weights have been adjusted by NCHS to yield unbiased national estimates of visit occurrences and characteristics. To provide accurate weighted estimates, a minimum sample size of 30 and a relative SE of less than 30% is required.
Descriptive statistics using survey weights were used to estimate the total number of outpatient and ED visits for eye pain. Weighted proportions were used to describe patient, visit, and physician characteristics. Estimates of categorical variables were compared using χ2 test. P < .05 was considered significant.
Results
From 2008 through 2019, there were 359 736 outpatient and 293 470 ED visits for eye pain resulting in an estimated 4.6 million (95% CI, 3.9 million to 5.3 million) outpatient and 1.0 million (95% CI, 0.8 million to 1.1 million) ED eye pain visits annually. eTable 2 in Supplement 1 presents eye pain visits by year. This represents approximately 0.39% (95% CI, 0.34%-0.44%) of all outpatient and 0.61% (95% CI, 0.57%-0.65%) of all ED visits annually. Eye pain was the primary RFV in 42.0% (95% CI, 37.8%-46.2%) of outpatient and 66.9% (95% CI, 62.9%-70.9%) of ED eye pain visits (P < .001). Eye pain was the only RFV in 18.3% (95% CI, 15.0%-21.7%) of eye pain–related outpatient visits and in 32.7% (95% CI, 29.0%-36.4%) of ED visits (P < .001).
Ophthalmologists conducted more outpatient eye pain visits than any other specialty (45.3% [95% CI, 38.8%-51.7%]). Patients presenting for eye pain–related outpatient visits were more often female (63.2% [95% CI, 59.4%-67.0%]) and older than 60 years (46.6% [95% CI, 42.4%-51.0%]) in the outpatient setting, whereas patients presenting for eye pain–related ED visits were more often male (51.8% [95% CI, 48.7%-55.0%]) and aged less than 45 years (aged <15 years: 16.4% [95% CI, 13.9%-18.8%]; 15-24 years: 19.2% [95% CI, 16.6%-21.7%]; and 25-44 years: 35.6% [95% CI, 32.7%-38.5%]). (Table 1). For nearly half of outpatient visits, the major problem was deemed nonacute (2.0 million [95% CI, 1.6 million to 2.3 million]). Compared with patients presenting for an acute visit, patients presenting for a nonacute eye pain visit were significantly more likely to be older than 45 years (all comparisons between groups with P < .001 include age 45-64 years, 65-74 years, and ≥75 years) and identify as Black or other (26.3% [95% CI, 20.8%-31.8%]) than White (16.5% [95% CI, 11.9%-21.1%]; P < .001). Additional demographic characteristics are provided in Table 1.
Table 1. Demographic Characteristics of Patients Who Presented for an Outpatient or Emergency Department Visit With Eye Pain Between 2008 and 2019 (Excluding 2017).
| Characteristic | % (95% CI) | |
|---|---|---|
| Outpatient setting | Emergency department | |
| Overall eye pain visits | ||
| Unweighted, No. | 359 736 | 293 470 |
| Weighted, No. (95% CI), in 100 000s | 46.2 (39.1-53.2) | 9.1 (8.1-10.2) |
| Patient level | ||
| Sex | ||
| Female | 63.2 (59.4-67.0) | 48.2 (45.0-51.3) |
| Male | 36.8 (33.0-40.6) | 51.8 (48.7-55.0) |
| Age group, y | ||
| <15 | 11.3 (7.6-15.0) | 16.4 (13.9-18.8) |
| 15-24 | 4.8 (3.3-6.3) | 19.2 (16.6-21.7) |
| 25-44 | 17.2 (13.6-20.8) | 35.6 (32.7-38.5) |
| 45-64 | 29.0 (25.1-33.0) | 22.4 (20.0-24.7) |
| 65-74 | 21.9 (18.5-25.3) | 3.9 (2.8-5.1) |
| ≥75 | 15.8 (13.2-18.4) | 2.6 (1.7-3.5) |
| Racea | ||
| White | 79.3 (75.5-83.1) | 68.9 (65.6-72.3) |
| Black | 13.4 (10.5-16.3) | 26.3 (23.0-29.7) |
| Otherb | 7.3 (4.6-10.0) | 4.7 (3.4-6.0) |
| Ethnicitya | ||
| Hispanic or Latino | 18.6 (14.9-22.3) | 16.8 (13.8-19.9) |
| Not Hispanic or Latino | 81.4 (77.7-85.1) | 83.2 (80.1-86.2) |
| Major problem type | ||
| Acute | 57.3 (52.8-61.8) | NA |
| Chronic | 42.8 (38.2-47.3) | |
| Geographic regionc | ||
| Northeast | 29.5 (13.0-45.9) | NA |
| Midwest | 19.3 (0.0-38.6) | |
| South | 32.7 (13.5-51.9) | |
| West | 18.6 (4.4-32.8) | |
The National Center for Health Statistics (NCHS) collects race and ethnicity data to help explain interrelated trends in the health data as well as examine in health status and access to care. Race and ethnicity were imputed by NCHS for each survey to account for missing data.
Other includes American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, or more than 1 race reported.
Geographic region of where the visit took place from 2008-2016. Estimates for the Midwest region may be inaccurate due to an SE of 33%.
The 5 most common additional RFVs for outpatient eye pain visits were abnormal color of eyes (eg, red eye and bloodshot eyes; 16.2% [95% CI, 13.1%-19.2%]), diminished vision (11.5% [95% CI, 8.8%-14.2%]), discharge from eye-tearing and/or eye watering (8.0% [95% CI, 5.7%-10.4%]), eye itching (6.1% [95% CI, 3.9%-8.3%]), and eye examination (5.0% [95% CI, 3.2%-6.7%]). For ED visits, the 5 most common additional RFVs were abnormal color of eyes (14.3% [95% CI, 12.0%-16.5%]), swelling of eyes (7.9% [95% CI, 6.0%-9.9%]), headache (7.4% [95% CI, 5.9%-8.9%]), diminished vision (5.7% [95% CI, 4.3%-7.1%]), and discharge from eye (5.1% [95% CI, 3.5%-5.8%]).
Table 2 summarizes the top 5 ICD-10 codes for eye pain visits. eTable 3 in Supplement 1 presents cross-walked ICD-9 codes. The most common primary diagnosis recorded for outpatient eye pain–related visits when pain was the primary RFV was ocular pain (ICD-10: H571; 16.4% [95% CI, 5.7%-27.2%]). None of the top 5 recorded diagnoses for outpatient visits was acutely vision-threatening (Table 2; eTable 1 in Supplement 1 for ICD-10 categorization), and 15.6% (95% CI, 2.7%-28.4%) had a systemic or neurologic diagnosis (eg, migraine) that is associated with eye pain. The primary diagnosis was non–vision threatening or not associated with eye pain for most outpatient visits (78.5% [95% CI, 56.8%-100%]). When eye pain was the only RFV, diagnoses were similar in the outpatient setting with the exception of zoster with other complications (B028), which was 1 of the top 5 recorded diagnoses and potentially vision-threatening (eTable 4 in Supplement 1). Among outpatient eye pain visits considered to be acute, the most common diagnosis was unspecified conjunctivitis (ICD-10: H109); for eye pain visits considered nonacute, it was open-angle glaucoma (ICD-10: H401).
Table 2. Five Most Common ICD-10 Diagnoses When Eye Pain Was the Primary Reason for Outpatient or Emergency Department Visit (2016, 2018, 2019).
| Setting and diagnosis (ICD-10 code) | Estimated presentation, % (95% CI) |
|---|---|
| Outpatient setting diagnosis | |
| Ocular pain (H571) | 16.4 (5.7-27.2) |
| Unspecified conjunctivitis (H109)a | 9.9 (0.0-21.2) |
| Keratoconjunctivitis (H162)a | 6.6 (0.0-18.1) |
| Unspecified iridocyclitis (H209)a | 6.6 (0.0-18.1) |
| Open-angle glaucoma (H401)a | 3.7 (0.0-9.1) |
| Emergency department diagnosis | |
| Injury of conjunctiva and corneal abrasion without foreign body (S050) | 22.0 (15.2-28.8) |
| Unspecified conjunctivitis (H109) | 8.5 (4.1-12.9) |
| Conjunctivitis (H10)a | 5.2 (1.3-9.1) |
| Ocular pain (H571)a | 5.1 (2.0-8.1) |
| Headache (R51)a | 3.5 (0.6-6.5) |
Abbreviation: ICD-10, International Statistical Classification of Diseases and Related Health Problems, Tenth Revision.
Estimates may be inaccurate as fewer than 30 visits were captured.
For ED visits, the most common diagnosis was injury of the conjunctiva and corneal abrasion without foreign body (ICD-10: S050; 22.0% [95% CI, 15.2%-28.8%]) when pain was the primary RFV, and 10.4% (95% CI, 5.2%-15.6%) had a systemic or neurologic diagnosis (eg, migraine) that is associated with eye pain. For 6.2% (95% CI, 2.8%-9.7%) of ED visits in which eye pain was the primary RFV, a diagnosis of ocular pain was either made in isolation or with other diagnoses not clearly associated with eye pain. However, the primary diagnosis was non–vision threatening or not associated with eye pain for most ED visits (69.9% [95% CI, 62.1%-77.7%]). Diagnoses were similar in the ED when eye pain was the only RFV (eTable 4 in Supplement 1).
Additional follow-up was recommended in most eye pain visits (89.4% [95% CI, 86.2%-92.6%]) and when eye pain was the primary RFV (90.8% [95% CI, 86.6%-95.0%]) or only RFV (88.9% [95% CI, 81.9%-95.9%]). When eye pain was the primary RFV in the outpatient setting, follow-up was recommended significantly more often when the problem was considered nonacute (93.6% [95% CI, 88.1%-99.2%]) rather than acute (89.5% [95% CI, 84.0%-95.0%]) (P < .001). Likewise, when the primary diagnosis was non–vision threatening, a systemic or neurologic diagnosis associated with eye pain, or ocular pain diagnosis alone, follow-up was recommended in 75.5% (95% CI, 60.9%-90.2%) of visits when eye pain was the primary RFV.
Discussion
We found that from 2008 through 2019, more than 5 million visits occurred annually in the US for eye pain. This likely represents an underestimation of eye pain visits as the dataset does not include optometrists. Most of these visits were outpatient, and for 42% of outpatient and 67% of ED visits, eye pain was the primary reason for seeking care. As expected, ophthalmologists conducted more eye pain visits in the outpatient setting than any other specialty. Patients presenting to outpatient clinics were more often women and older, whereas clear sex differences were not observed in the ED. Furthermore, most ED (70%) and outpatient (79%) eye pain visits did not result in a primary diagnosis for a vision-threatening condition. Yet approximately 75% to 90% of all eye pain visits, even when eye pain was the primary or only RFV or the primary diagnosis is not vision-threatening, result in a recommendation for additional care. Expanding and tailoring our therapeutic approaches to treating the underlying causes of eye pain will be key to reducing the burden of eye pain on the health care system and optimizing patient outcomes.
To our knowledge, this is the first study to provide nationally representative data regarding eye pain visits in the US. Many prior studies9,10,11,12,13,14,15 have attempted to estimate the prevalence of specific eye discomfort symptoms (eg, irritation, discomfort, burning, grittiness, foreign body sensation, dryness) typically associated with dry eye disease, a leading cause of chronic eye pain. Although these studies show the high prevalence of these symptoms in the general population ranging from 17% to 51%, none estimate the burden of these symptoms on the US health care system. Those studies that do attempt to estimate the burden that eye pain imposes on the health care system have focused on either patient or clinician reports outside of the US or specific diagnoses (eg, dry eye disease) rather than focusing on eye pain as a whole.4,5,6 When eye pain was the primary RFV and the major problem was deemed to be nonacute, more follow-up visits (ie, health care utilization) were recommended compared with acute visits. Additionally, we found that 10% to 15% of outpatient and ED eye pain visits resulted in a diagnosis for a systemic or neurologic condition potentially associated with eye pain, nearly all of which are associated with chronic eye pain. Further research should delineate the mechanisms underlying chronic eye pain so clinicians can tailor treatments more effectively and identify the modifiable factors that induce a transition from acute to chronic eye pain.
Although none of the top 5 most common diagnoses for outpatient eye pain visits were acutely vision-threatening, the same cannot be said for eye pain visits to the ED. This study found that the leading primary diagnosis for eye pain visits to the ED is trauma to the conjunctiva or cornea (22% of ED eye pain visits). However, the primary diagnosis for most (70%) ED eye pain visits were for non–vision-threatening diagnoses or diagnoses not associated with eye pain. Similarly, in a prior study16 using the Nationwide Emergency Department Sample, only 41% of ED-related eye visits were considered emergent. Furthermore, when diagnoses are potentially vision-threatening, anterior segment injuries appear most common both in our study and others.16,17 As in our study, these prior studies also found that eye-related ED visits in the US are highest among younger individuals aged 18 to 39 years. Interventions that promote timely outpatient care for eye-related concerns should also focus on patients with eye pain to prevent unnecessary use of limited ED resources.
Strengths and Limitations
The strengths of our study include its large sample size and the sampling design that allow for nationally representative estimates. The study also includes a large number of patient and visit-level variables. However, our study also has important limitations. First, the data are cross-sectional and therefore patients cannot be followed longitudinally. Changes have also occurred within the survey over time. As a result, several of our estimates were based on less than 10 years of data. Similarly, several of the estimates for individual diagnoses are too small and may be inaccurate. These should be considered more qualitatively in light of the other reliable estimates. In years 2014 to 2019, the RFV and diagnoses variables allowed 5 rather than only 3 responses. Because these changes could bias reports of trends, we limited our analysis to pooled estimates. Variables are also limited to those defined by NCHS, and some variables are captured only within the outpatient survey and not the ED survey (eg, visit type). Additionally, we chose not to include medications in our study, although available in the data, given the difficulty determining the reason for prescribing and changes in reporting across years. Optometry practices are not sampled in NAMCS/NHAMCS; therefore, our estimates likely underestimate eye pain visits in the US and may miss patients with pain managed by optometrists. There are also certain populations of patients that this study may inadequately capture, such as patients with mild acute symptoms that were self-managed, patients who were unable to attend or access health care, and patients with relatively well-controlled chronic symptoms.
Conclusions
More than 5 million visits occur annually in the US for eye pain; the largest percentage take place in the outpatient setting with ophthalmologists, and visits for nonacute causes of eye pain are common. In 42% of outpatient visits and 67% of ED visits, eye pain was the primary reason for seeking care, and most primary diagnoses were non–vision threatening. Expanding and tailoring our therapeutic approaches to the underlying causes of eye pain will be key to reducing the burden of eye pain on the health care system and optimizing patient outcomes.
eTable 1. Outpatient and Emergency Department ICD-10 Diagnoses Code Categorization
eTable 2. Estimated Outpatient and Emergency Department Visits for Eye Pain by Year
eTable 3. Five Most Common ICD-10-CM Diagnoses and Possible Corresponding ICD-9-CM Diagnoses When Eye Pain Was the Primary Reason for Outpatient or Emergency Department Visit (2016, 2018, 2019)
eTable 4. Five Most Common ICD-10-CM Diagnoses When Eye Pain Was the Only Reason for Outpatient or Emergency Department Visit (2016, 2018, 2019)
Data Sharing Statement
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eTable 1. Outpatient and Emergency Department ICD-10 Diagnoses Code Categorization
eTable 2. Estimated Outpatient and Emergency Department Visits for Eye Pain by Year
eTable 3. Five Most Common ICD-10-CM Diagnoses and Possible Corresponding ICD-9-CM Diagnoses When Eye Pain Was the Primary Reason for Outpatient or Emergency Department Visit (2016, 2018, 2019)
eTable 4. Five Most Common ICD-10-CM Diagnoses When Eye Pain Was the Only Reason for Outpatient or Emergency Department Visit (2016, 2018, 2019)
Data Sharing Statement
