In a 75-year-old patient with hypertension, type 2 diabetes, dyslipidemia, taking losartan, amlodipine, metformin, atorvastatin, and empagliflozin, and a known right‑eye pterygium, who presents with a 36‑hour history of a vague foreign‑body sensation in the eye without redness, visual changes, motility deficit, fever, edema, or discharge, and a normal fundus examination, what is the most likely diagnosis?

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Last updated: September 15, 2026 • View editorial policy

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Diagnóstico Más Probable: Pterigión Sintomático

El diagnóstico más probable en este paciente es irritación ocular secundaria al pterigión conocido en ojo derecho, que puede causar sensación de cuerpo extraño sin otros hallazgos inflamatorios agudos.

Razonamiento Clínico

Hallazgos Clave que Apoyan el Diagnóstico

El paciente presenta:

  • Sensación "extraña" en ojo (típica de irritación por pterigión)
  • Pterigión conocido en ojo derecho documentado en examen
  • Ausencia de signos inflamatorios agudos: sin ojo rojo, sin secreción, sin edema, sin fiebre
  • Examen ocular normal excepto por el pterigión
  • Fondo de ojo normal reciente

Contexto del Pterigión

El pterigión es un crecimiento fibrovascular benigno de la conjuntiva que puede causar:

  • Sensación de cuerpo extraño intermitente
  • Irritación ocular vaga sin signos inflamatorios evidentes
  • Síntomas que fluctúan con sequedad ocular, exposición ambiental
  • Molestias que pueden aparecer súbitamente sin cambios en el examen físico

Diagnósticos Descartados

Conjuntivitis infecciosa: Descartada por ausencia de ojo rojo, secreción patológica, y signos inflamatorios 1

Neuropatía óptica isquémica anterior (NOIA): Aunque el paciente tiene factores de riesgo (75 años, DM2, HTA), la NOIA típicamente presenta:

  • Pérdida visual súbita y severa (no solo sensación extraña)
  • Defecto pupilar aferente
  • Edema de disco óptico
  • El fondo de ojo reciente fue normal 2

Retinopatía hipertensiva aguda: La presión arterial del paciente está razonablemente controlada (143/79 mmHg), sin evidencia de crisis hipertensiva que causaría cambios fundoscópicos agudos 3

Efectos adversos medicamentosos: Los fármacos del paciente (losartan, amlodipino, metformina, atorvastatina, empagliflozina) no causan típicamente sensación de cuerpo extraño ocular aislada 456

Manejo Recomendado

Tratamiento conservador inicial:

  • Lágrimas artificiales sin preservantes 4-6 veces al día
  • Evitar irritantes ambientales (viento, polvo, aire acondicionado directo)
  • Seguimiento en 1-2 semanas

Criterios de referencia a oftalmología:

  • Progresión del pterigión hacia zona visual
  • Persistencia o empeoramiento de síntomas
  • Desarrollo de cambios visuales
  • Signos inflamatorios nuevos

Advertencia Importante

Aunque el pterigión es el diagnóstico más probable, cualquier cambio en la agudeza visual, aparición de dolor significativo, o desarrollo de ojo rojo requiere evaluación oftalmológica urgente para descartar patología más seria, especialmente dado el perfil de riesgo cardiovascular y metabólico del paciente.

References

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