What is the appropriate evaluation and management for a patient presenting with eye pain?

Evaluation and Management of Eye Pain

A comprehensive ocular examination is essential for all patients presenting with eye pain, including visual acuity assessment, external examination, pupillary testing, ocular motility evaluation, slit-lamp biomicroscopy, and fundus examination to identify the underlying cause and prevent vision loss. 1

Initial Assessment

History

• Characterize the pain: burning, stinging, aching, foreign body sensation
• Onset, duration, and severity of symptoms
• Associated symptoms:
  • Visual changes (decreased acuity, blurring)
  • Photophobia
  • Redness
  • Tearing
  • Pain with eye movement
  • Headache
• Exacerbating/relieving factors
• Recent trauma, surgery, or infection
• Contact lens wear history
• Systemic conditions (autoimmune disorders, vascular disease)
• Current medications

Examination Components

1. Visual acuity with current correction
2. External examination:
   • Eyelid position and function
   • Lacrimal apparatus
   • Globe position
   • Skin and facial features
3. Pupillary function:
   • Size and response to light
   • Relative afferent pupillary defect (critical for optic nerve pathology)
4. Ocular alignment and motility
5. Slit-lamp biomicroscopy:
   • Eyelid margins and lashes
   • Tear film quality and quantity
   • Conjunctiva (hyperemia, follicles, discharge)
   • Cornea (abrasions, infiltrates, edema)
   • Anterior chamber (cells, flare)
   • Iris and lens
6. Intraocular pressure measurement (may be deferred with suspected infection/trauma)
7. Fundus examination (optic nerve, retina, vasculature)

Diagnostic Testing Based on Suspected Etiology

For Ocular Surface Disease

• Tear film break-up time
• Ocular surface staining (fluorescein, lissamine green)
• Schirmer testing
• "Anesthetic challenge test" for neuropathic pain 1

For Suspected Optic Neuritis

• Visual field testing (central or arcuate defects)
• Color vision testing
• MRI orbits/brain with contrast
• Visual evoked potentials 2

For Suspected Glaucoma

• Tonometry (intraocular pressure)
• Gonioscopy (anterior chamber angle assessment)

Common Causes of Eye Pain and Management

1. Ocular Surface Disorders

• Dry Eye Syndrome

  • Treatment: Preservative-free artificial tears, anti-inflammatory therapy, punctal plugs
  • Consider autologous serum tears for neuropathic component 1

• Corneal Abrasion

  • Treatment: Antibiotic drops, cycloplegics for comfort, patching controversial

2. Inflammatory Conditions

• Anterior Uveitis

  • Treatment: Topical steroids, cycloplegics
  • Requires ophthalmology consultation 3

• Scleritis

  • Treatment: Oral NSAIDs, systemic steroids
  • Requires urgent ophthalmology consultation 4

3. Infectious Conditions

• Keratitis (bacterial, viral, fungal)
  • Treatment: Appropriate antimicrobial therapy
  • Requires urgent ophthalmology consultation 3

4. Neurologic Causes

• Optic Neuritis

  • Treatment: IV methylprednisolone (1g/day for 3-5 days), followed by oral prednisone taper
  • Requires neuroimaging and neurology consultation 2

• Neuropathic Ocular Pain

  • Treatment: Depends on location of nerve dysfunction
  • Peripheral: Topical nerve regenerative therapies
  • Central: Oral neuromodulators (pregabalin, gabapentin, duloxetine, amitriptyline) 1

5. Emergent Conditions

• Acute Angle-Closure Glaucoma

  • Treatment: Immediate IOP lowering (topical beta-blockers, alpha-agonists, oral/IV acetazolamide)
  • Requires immediate ophthalmology consultation 5, 4

• Orbital Cellulitis

  • Treatment: IV antibiotics, possible surgical drainage
  • Requires immediate hospitalization and ophthalmology/ENT consultation

Red Flags Requiring Immediate Ophthalmology Consultation

• Severe pain with nausea/vomiting
• Acute vision loss
• Pain with eye movement
• Optic disc edema
• Proptosis
• Pupillary abnormalities
• Corneal opacity or infiltrate
• Anterior chamber inflammation
• Elevated intraocular pressure 3

Pitfalls to Avoid

1. Failing to check visual acuity - This is the vital sign of the eye
2. Missing a relative afferent pupillary defect - Critical for diagnosing optic nerve pathology
3. Overlooking neuropathic pain - Symptoms may outweigh signs; consider when pain persists despite appropriate treatment 1
4. Delaying referral for vision-threatening conditions - Acute angle-closure glaucoma, infectious keratitis, and optic neuritis require urgent specialist care
5. Attributing all eye pain to dry eye - Consider the full differential diagnosis, especially when symptoms are severe or persistent

Remember that eye pain can be the first sign of a vision-threatening condition, and timely diagnosis and management are crucial for preserving visual function and quality of life.