Differential Diagnosis for Eye Pain

The patient presents with episodic, cramping-type eye pain that is bilateral, triggered by looking far without wearing glasses, and associated with tearing and blurry vision. Given the symptoms and history, the differential diagnosis can be categorized as follows:

• Single Most Likely Diagnosis

  • Refractive Error (e.g., Myopia, Hyperopia, Astigmatism): The pain triggered by looking far without glasses, along with blurry vision, strongly suggests that the patient's symptoms are related to an uncorrected refractive error. The cramping pain could be due to prolonged use of the eyes for near or far vision without adequate correction, leading to eye strain.

• Other Likely Diagnoses

  • Dry Eye Syndrome: Although the patient denies foreign body sensation, the presence of tearing and blurry vision, especially when pain occurs, could suggest dry eye syndrome, particularly if the tearing is a reflex to irritation rather than an indication of adequate tear production.
  • Accommodative Spasm: This condition involves involuntary contraction of the ciliary muscles, leading to cramping pain, blurry vision, and sometimes tearing, which fits the patient's symptoms. It can be triggered by prolonged near work or uncorrected refractive errors.
  • Convergence Insufficiency: This is a condition where the eyes have difficulty working together, leading to symptoms like eye strain, blurry vision, and sometimes pain when performing tasks that require focusing on distant objects.

• Do Not Miss Diagnoses

  • Acute Angle-Closure Glaucoma: Although the patient denies photophobia, redness, and severe pain, which are typical symptoms, it's crucial to rule out glaucoma due to its potential for irreversible vision loss. The absence of these symptoms does not entirely exclude the diagnosis.
  • Optic Neuritis: This condition can present with pain on eye movement and decreased vision, but it typically affects one eye at a time. However, given the potential for serious underlying conditions like multiple sclerosis, it's essential to consider and rule out optic neuritis.
  • Temporal Arteritis (Giant Cell Arteritis): This condition can cause headache, jaw claudication, and visual disturbances, including blurry vision and pain. Although the patient denies headache and is relatively young, the diagnosis should be considered in the differential due to its potential for causing blindness.

• Rare Diagnoses

  • Ocular Migraine: These can cause visual disturbances, including blurry vision and sometimes pain, but they are typically accompanied by other migraine symptoms like headache or aura.
  • Sjögren's Syndrome: An autoimmune disorder that can cause dry eyes and other systemic symptoms. While less likely given the lack of other symptoms, it could be considered if other diagnoses are ruled out and the patient continues to experience eye discomfort.
  • Thyroid Ophthalmopathy: Can cause eye pain, blurry vision, and tearing, but it's usually associated with other signs of thyroid disease and exophthalmos, which are not mentioned in the patient's history.