What could be causing dizziness, visual disturbances, and pressure around the right eye?

Dizziness, Visual Disturbances, and Pressure Around Right Eye

This symptom triad requires urgent ophthalmologic evaluation to rule out acute angle-closure crisis, which can cause permanent vision loss within hours if untreated, followed by assessment for posterior circulation stroke if ocular pathology is excluded. 1

Immediate Ophthalmologic Assessment

The combination of visual disturbances and periocular pressure is highly concerning for primary angle-closure disease, which presents as an ophthalmic emergency. 1

Key Features of Acute Angle-Closure Crisis:

• Sudden onset of eye pain and pressure (particularly unilateral around one eye) 1
• Visual disturbances including blurred vision, halos around lights, and decreased vision 1
• Associated symptoms of headache, eye redness, nausea, and vomiting 1
• Mid-dilated, poorly reactive pupil in the affected eye 1
• Corneal edema causing visual blurring 1
• Markedly elevated intraocular pressure (often >40 mmHg) 1

Critical action: Measure intraocular pressure immediately and perform gonioscopy to assess anterior chamber angle. 1 If acute angle-closure is confirmed, this requires immediate treatment with topical ocular hypotensive agents and urgent laser peripheral iridotomy within hours to prevent permanent vision loss and glaucomatous optic neuropathy. 1

Neurologic Evaluation if Ophthalmologic Causes Excluded

If intraocular pressure is normal and angle-closure is ruled out, posterior circulation stroke or transient ischemic attack becomes the primary concern given the triad of dizziness and visual symptoms. 1, 2

Orthostatic Intolerance Syndromes:

The European Heart Journal guidelines specifically identify this symptom constellation as characteristic of orthostatic hypotension: 1

• Dizziness/lightheadedness 1
• Visual disturbances (blurring, enhanced brightness, tunnel vision) 1
• Symptoms occurring 30 seconds to 3 minutes after standing 1

Perform lying-to-standing blood pressure measurement to detect orthostatic hypotension (drop in systolic BP ≥20 mmHg or diastolic BP ≥10 mmHg within 3 minutes of standing). 1

Vertebrobasilar Insufficiency:

Stroke accounts for 3-7% of all vertigo/dizziness presentations, with the vertebrobasilar system supplying the inner ear, brainstem, and cerebellum. 2

Red flags requiring urgent neuroimaging: 1, 2

• Sudden onset of symptoms 2
• Downbeating nystagmus on examination (suggests central pathology) 1
• Direction-changing nystagmus without head position changes 1
• Associated neurologic deficits including dysarthria, dysmetria, dysphagia, sensory/motor loss, or Horner's syndrome 1
• Severe headache (particularly occipital/neck pain) 1

Diagnostic Algorithm

Step 1: Ophthalmologic Emergency Assessment

• Measure intraocular pressure in both eyes 1
• Slit-lamp examination for corneal edema, anterior chamber depth, pupil reactivity 1
• Gonioscopy to assess anterior chamber angle 1
• If IOP elevated or angle narrow: Immediate treatment and urgent laser iridotomy 1

Step 2: Cardiovascular Assessment (if ophthalmologic exam normal)

• Orthostatic vital signs (lying, sitting, standing at 1 and 3 minutes) 1
• Medication review for vasoactive drugs, diuretics, anticholinergics 1
• Cardiac examination for arrhythmias 1

Step 3: Neurologic Assessment

• Detailed neurologic examination including cranial nerves, cerebellar testing, sensory/motor function 1, 2
• Nystagmus assessment (direction, persistence, effect of visual fixation) 1
• Dix-Hallpike maneuver if symptoms are positional 1, 3
• HINTS examination (Head Impulse, Nystagmus, Test of Skew) if acute vestibular syndrome present 3, 4

Step 4: Imaging (if indicated by examination)

• Brain MRI with diffusion-weighted imaging is superior to CT for detecting posterior circulation stroke 2
• MRA or CTA of vertebrobasilar system if vascular etiology suspected 2
• CT head only if hemorrhage suspected or MRI unavailable 2

Common Pitfalls to Avoid

Do not dismiss unilateral eye pressure as "sinus headache" – acute angle-closure can present with periocular/frontal pressure that mimics sinus disease but requires emergent treatment. 1

Do not attribute all dizziness with visual symptoms to benign positional vertigo – the presence of persistent visual disturbances and localized eye pressure suggests either ophthalmologic or vascular pathology requiring urgent evaluation. 1, 3, 2

Do not order routine laboratory tests or EKG without clinical indication – the diagnostic yield is extremely low in unselected patients with dizziness, and testing should be guided by history and examination findings. 5

Avoid medications with anticholinergic properties (over-the-counter cold/allergy medications, sleeping aids) in patients with narrow angles, as these can precipitate acute angle-closure. 1