What is the best course of action for a 100-year-old woman with a history of hypertension (high blood pressure) presenting with left eye pain, no drainage, and no photophobia?

Management of Left Eye Pain in a 100-Year-Old Woman with Hypertension

For a 100-year-old woman with hypertension presenting with left eye pain without drainage or photophobia, urgent ophthalmological evaluation is necessary to rule out temporal arteritis, which is a medical emergency requiring immediate treatment.

Initial Assessment

Key Symptoms to Evaluate

• Characteristics of eye pain (onset, duration, severity)
• Associated symptoms:
  • Presence of headache, especially temporal headache
  • Jaw claudication
  • Scalp tenderness
  • Visual changes or vision loss
  • Systemic symptoms (fever, weight loss, fatigue)

Physical Examination

• Vital signs with focus on blood pressure
• Visual acuity assessment
• Pupillary responses
• Ocular motility
• Inspection of temporal arteries for prominence or tenderness
• Fundoscopic examination to check for retinal changes

Differential Diagnosis

1. Temporal arteritis (Giant Cell Arteritis) - Most concerning in this age group
2. Hypertensive retinopathy or choroidopathy
3. Glaucoma (acute or chronic)
4. Dry eye syndrome
5. Ocular ischemic syndrome

Immediate Management

Laboratory Testing

• Erythrocyte sedimentation rate (ESR)
• C-reactive protein (CRP)
• Complete blood count
• Blood glucose, HbA1c
• Blood pressure measurement

If Temporal Arteritis is Suspected

If the patient has scalp tenderness, jaw claudication, or elevated inflammatory markers:

1. Start high-dose oral corticosteroids immediately without waiting for biopsy results 1
2. Arrange for temporal artery biopsy within 1-2 weeks of starting steroids
3. Refer to ophthalmology urgently (same day)

If Hypertensive Crisis is Suspected

If BP >180/120 mmHg with signs of end-organ damage:

1. Hospitalize immediately in ICU with continuous BP monitoring
2. Initiate IV antihypertensive therapy with titratable short-acting agents
3. Reduce BP by no more than 25% within the first hour, then to 160/100 mmHg within 2-6 hours 2

Age-Specific Considerations

For a 100-year-old patient:

• Medication dosing should be more gradual due to higher risk of adverse effects 3
• Monitor for postural hypotension when initiating or adjusting antihypertensive therapy
• Consider comorbidities and polypharmacy when selecting treatments

Management Based on Specific Diagnoses

If Temporal Arteritis

• High-dose oral prednisone (40-60 mg daily)
• Ophthalmology follow-up within 24-48 hours
• Temporal artery biopsy to confirm diagnosis
• Long-term steroid management with slow taper

If Hypertensive Retinopathy/Choroidopathy

• Control blood pressure according to age-appropriate targets
• Thiazide diuretics, calcium channel blockers, or ACE inhibitors are appropriate first-line agents in the elderly 3
• Target BP <140/90 mmHg if tolerated 3

If Glaucoma

• Refer to ophthalmology immediately
• Initiate pressure-lowering eye drops as directed by ophthalmologist

Important Pitfalls to Avoid

1. Delaying treatment for suspected temporal arteritis - Can lead to permanent vision loss
2. Overlooking temporal arteritis due to normal inflammatory markers - ESR and CRP can be normal in up to 10% of cases 4
3. Lowering blood pressure too rapidly - Can cause cerebral, cardiac, or renal hypoperfusion 2
4. Assuming eye pain in an elderly patient is benign - Always consider vision-threatening conditions first

Follow-up Recommendations

• If temporal arteritis is diagnosed: Weekly follow-up initially to monitor response to steroids
• If hypertensive retinopathy: Follow-up within 1-2 weeks to assess BP control
• For all patients: Regular monitoring of vision and eye symptoms

Remember that prompt recognition and management of potential emergencies like temporal arteritis can prevent devastating consequences such as permanent vision loss in this vulnerable age group.