Management of Red, Painful Eye with Proptosis and Partial Response to Prednisone Drops
This patient requires URGENT ophthalmology referral immediately—proptosis with eyelid swelling, pain, erythema, pain with eye movements, and vision changes are warning signs that demand same-day specialist evaluation, as these features suggest serious orbital pathology such as preseptal/orbital cellulitis, orbital myositis, thyroid eye disease, or carotid-cavernous fistula rather than simple inflammatory conditions. 1
Immediate Actions
Stop topical corticosteroids immediately until ophthalmology examination is completed. Starting or continuing steroids before a comprehensive eye exam can worsen infectious conditions (such as herpetic keratitis or uveitis) and mask accurate diagnosis and severity grading. 1, 2
Critical Warning Signs Present
The combination of findings in this patient represents multiple red flags:
- Proptosis (forward displacement of the globe) 1
- Pain with eye movements 1
- Eyelid swelling with erythema 1
- Partial response to topical steroids (suggesting inadequate treatment or wrong diagnosis) 1
- History of extensive massage (may indicate trauma or vascular injury) 3
Differential Diagnosis Requiring Urgent Evaluation
Most Likely Serious Conditions
Orbital cellulitis or preseptal cellulitis requires systemic antibiotic treatment and urgent ophthalmology consultation. 1
Carotid-cavernous fistula (CCF) can present with red eye, proptosis, elevated intraocular pressure, and dilated conjunctival vessels—particularly relevant given the history of massage/trauma. This requires digital subtraction angiography for diagnosis. 3
Orbital myositis presents with painful eye movements, proptosis, and conjunctival hyperemia, typically responsive to systemic (not topical) prednisone. 4
Thyroid eye disease causes proptosis, extraocular muscle enlargement, and exposure keratopathy requiring aggressive ocular lubrication and potentially systemic treatment. 1, 5
Diagnostic Workup Required by Ophthalmology
The ophthalmologist should perform:
- Slit lamp examination to assess anterior segment and rule out uveitis, keratitis, or scleritis 1
- Dilated fundus examination to evaluate optic nerve and retina 1
- Intraocular pressure measurement (elevated IOP can occur with CCF or orbital congestion) 3
- Exophthalmometry to quantify proptosis 1
- Assessment of extraocular motility and forced duction testing 1
- Pupillary examination including afferent pupillary defect testing 1
Imaging Studies
MRI of the orbits with and without contrast is the optimal imaging modality for suspected orbital mass, optic nerve pathology, or soft tissue inflammation. 1
CT of the orbits with contrast is complementary and particularly useful for:
- Evaluating bony anatomy 1
- Assessing extraocular muscle enlargement (thyroid eye disease, orbital myositis) 1
- Identifying enlarged superior ophthalmic vein (suggests CCF) 3
- Evaluating orbital apex crowding 1
Digital subtraction angiography (DSA) should be performed if CCF is suspected based on clinical features and CT/MRI findings. 3
Treatment Approach Based on Diagnosis
If Orbital/Preseptal Cellulitis
- Systemic antibiotics immediately (not topical therapy) 1
- Hospitalization may be required for IV antibiotics
- Monitor for progression to orbital apex syndrome or cavernous sinus thrombosis
If Orbital Myositis
- Systemic corticosteroids (1-2 mg/kg/day prednisone equivalent), not topical drops 4
- Symptoms typically improve within days to weeks
- Recurrent cases may require immunosuppression
If Thyroid Eye Disease
- Aggressive ocular lubrication with preservative-free drops for exposure keratopathy 5
- Consider punctal plugs 1
- Smoking cessation counseling 1
- Endocrinology referral for thyroid function management 1
- Consider teprotumumab for active disease with significant proptosis 1
- Orbital decompression may be needed for compressive optic neuropathy 1
If Carotid-Cavernous Fistula
- Maximum medical therapy for elevated IOP (timolol, latanoprost) 3
- Interventional neuroradiology consultation for endovascular treatment
- Monitor for vision-threatening complications
Critical Pitfalls to Avoid
Do not continue topical corticosteroids alone for a patient with proptosis and systemic signs—this suggests orbital (not just ocular surface) pathology requiring systemic treatment or surgical intervention. 1, 2
Do not delay ophthalmology referral even if symptoms seem to partially improve with topical steroids—proptosis with pain and eye movement restriction represents potential vision-threatening or life-threatening conditions. 1
Do not assume this is simple conjunctivitis or episcleritis—these conditions do not cause proptosis or significant pain with eye movements. 3, 6
Prolonged topical corticosteroid use risks glaucoma, cataract formation, corneal perforation in thin tissue, and masking/exacerbating viral infections (particularly herpes simplex). 2