Differential Diagnosis for Acute Onset of Headache and Eye Pain

The patient's presentation of acute onset headache, eye pain, cloudy vision, and difficulty opening the affected eye, especially in the context of a recent glaucoma diagnosis and use of eye drops, suggests several potential diagnoses. These can be categorized as follows:

• Single Most Likely Diagnosis

  • Acute Angle-Closure Glaucoma: This condition is highly likely given the patient's recent diagnosis of glaucoma and the symptoms presented. Acute angle-closure glaucoma is an ocular emergency characterized by sudden increased intraocular pressure, which can cause severe eye pain, headache, blurred vision, and difficulty opening the eye due to pain and possible eyelid swelling. The use of certain medications, including some eye drops, can precipitate an attack.

• Other Likely Diagnoses

  • Conjunctivitis or Keratitis: Inflammation or infection of the conjunctiva or cornea could cause eye pain, redness, and a sensation of something being in the eye. While these conditions are less likely to cause the acute onset of severe headache and cloudy vision, they should be considered, especially if the patient has been using eye drops that could potentially cause irritation or if there's a history of exposure to infectious agents.
  • Uveitis: Inflammation of the uvea can cause eye pain, sensitivity to light, and vision problems. It might be less likely given the acute onset and specific symptoms but should be considered, especially if there's an underlying systemic condition that could predispose to uveitis.

• Do Not Miss Diagnoses

  • Endophthalmitis: Although less common, this is a severe infection within the eye that can occur, especially in patients using eye drops or following eye surgery. It's crucial to diagnose and treat promptly to prevent vision loss.
  • Orbital Cellulitis: An infection of the tissues surrounding the eye can cause pain, swelling, and vision changes. It's a serious condition that requires immediate antibiotic treatment.
  • Temporal Arteritis (Giant Cell Arteritis): This condition, more common in older adults, can cause headache, jaw claudication, and visual disturbances, including blindness if not promptly treated. It's essential to consider this diagnosis due to the patient's age and symptoms.

• Rare Diagnoses

  • Ocular Migraine: While migraines can cause visual disturbances, they are less likely to cause the specific combination of severe eye pain, difficulty opening the eye, and cloudy vision as presented.
  • Scleritis: Inflammation of the sclera can cause severe eye pain and vision problems but is less common and might not fully explain the acute onset of all symptoms described.

Workup in the Emergency Department

Given the potential for serious conditions, the workup should include:

• Visual Acuity Test: To assess the severity of vision impairment.
• Intraocular Pressure (IOP) Measurement: Crucial for diagnosing acute angle-closure glaucoma.
• Slit-Lamp Examination: To examine the anterior segment of the eye for signs of glaucoma, uveitis, or other conditions.
• Fundoscopic Examination: To evaluate the posterior segment for signs of increased pressure or other pathology.
• Complete Blood Count (CBC) and Blood Cultures: If infection is suspected.
• Imaging Studies (CT or MRI): If orbital cellulitis or other conditions affecting the orbit are considered.
• Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP): To evaluate for temporal arteritis, especially in patients over 50 years old presenting with new-onset headache and visual symptoms.
• Immediate Ophthalmology Consultation: Given the potential for ocular emergencies that require prompt intervention.