What is the appropriate workup for eye pain in a 70-year-old patient with glaucoma?

Workup of Eye Pain in a 70-Year-Old with Glaucoma

The workup of eye pain in a 70-year-old with glaucoma should begin with an urgent assessment to rule out acute angle-closure glaucoma, which is an ophthalmic emergency requiring immediate intervention to prevent vision loss.

Initial Assessment

History

• Onset and characteristics of pain (sudden vs. gradual)
• Associated symptoms:
  • Visual changes (blurry vision, halos around lights)
  • Headache
  • Nausea or vomiting
  • Photophobia
• Recent medication changes (especially anticholinergics, adrenergics, sulfonamides, topiramate) 1
• History of trauma
• Timing of last glaucoma medication administration
• Family history of acute glaucoma episodes

Physical Examination

1. Visual acuity measurement - critical baseline assessment 1
2. Pupil examination - check for:
   • Mid-dilated, poorly reactive, or oval pupil (suggestive of acute angle closure) 1
   • Relative afferent pupillary defect (may indicate optic nerve damage) 1
3. Slit-lamp biomicroscopy to evaluate:
   • Conjunctival hyperemia
   • Corneal clarity (edema suggests acute angle closure)
   • Anterior chamber depth and inflammation
   • Iris abnormalities (atrophy, posterior synechiae)
   • Lens changes (cataract, glaukomflecken) 1
4. Intraocular pressure (IOP) measurement - critical to identify elevated pressure 1
5. Gonioscopy - to assess angle configuration 1
6. Optic nerve head and retinal nerve fiber layer evaluation 1

Differential Diagnosis and Specific Evaluations

1. Acute Angle-Closure Glaucoma

• Signs: Elevated IOP, shallow anterior chamber, mid-dilated pupil, corneal edema
• Requires immediate ophthalmology referral 2, 3
• May present with headache, nausea, vomiting, and blurred vision 4, 5

2. Acute Primary Open-Angle Glaucoma Exacerbation

• Check medication compliance
• Evaluate for optic nerve changes
• Assess for progression of visual field defects 1

3. Retinal or Ophthalmic Artery Occlusion

• Evaluate for retinal pallor or cherry-red spot
• Assess for emboli
• Consider urgent stroke evaluation if suspected 1

4. Anterior Segment Inflammation/Uveitis

• Check for anterior chamber cells and flare
• Evaluate for keratic precipitates 3

5. Blepharitis/External Eye Disease

• Evaluate lid margins for crusting, debris, or meibomian gland dysfunction
• Check for corneal involvement 1

Management Algorithm

1. If IOP is significantly elevated with signs of acute angle closure:

   • Immediate ophthalmology referral (same day)
   • Do not dilate the pupil 1, 2

2. If IOP is elevated but no signs of acute angle closure:

   • Review medication compliance
   • Consider adding or adjusting IOP-lowering medication
   • Ophthalmology referral within 1-2 days 1

3. If IOP is normal but pain persists:

   • Consider anterior segment inflammation, corneal pathology, or external eye disease
   • Ophthalmology referral within 1-7 days depending on severity 1, 3

4. If signs of retinal artery occlusion are present:

   • Immediate referral to stroke center or emergency department
   • Ophthalmology consultation within 24 hours 1

Important Considerations and Pitfalls

• Never delay assessment of eye pain in a glaucoma patient - acute angle closure is an emergency that can cause permanent vision loss 2, 4
• Beware of medication-induced angle closure - many systemic and topical medications can precipitate an attack in predisposed individuals 4, 5
• Don't assume eye pain is always from glaucoma - consider other causes such as corneal abrasion, infection, or inflammatory conditions 3
• Central corneal thickness affects IOP readings - patients with thin corneas may have falsely low readings 1
• Recent cataract surgery or LASIK may affect IOP measurements and should be considered when interpreting results 1

Follow-up Recommendations

• For stable glaucoma patients without acute pathology: follow-up every 3-6 months
• For patients with progression or uncontrolled IOP: follow-up every 1-2 months
• For patients after acute angle closure episode: follow-up according to ophthalmologist's recommendation, typically within 1-2 weeks 1