What is the differential diagnosis (Ddx) for a patient presenting with bilateral eye pain and pressure?

Differential Diagnosis for Bilateral Eye Pain and Pressure

Bilateral eye pain and pressure most critically suggests intermittent angle-closure glaucoma, which carries a 50% risk of acute crisis within 5 years if untreated and an 18% risk of permanent blindness—making urgent ophthalmology referral with gonioscopy mandatory. 1, 2

Vision-Threatening Emergencies Requiring Immediate Action

Intermittent Angle-Closure Glaucoma (Primary Consideration)

• The bilateral presentation combined with pressure sensation is pathognomonic for intermittent angle closure, particularly if accompanied by transient blurred vision and halos around lights. 3, 2
• Halos result from pressure-induced corneal edema during episodes when intraocular pressure rises. 2
• Episodes are self-limiting because pupillary block breaks spontaneously before permanent damage occurs, but this does not reduce urgency. 2
• Critical examination findings include mid-dilated pupil (4-6mm), poor pupillary reactivity, or oval pupil shape during or after an attack. 1, 3
• Risk factors include hyperopia, age over 50, female gender, Asian or Inuit ethnicity, shallow anterior chamber, and family history. 1, 2

Acute Angle-Closure Crisis

• Presents with severe unilateral or bilateral pain, markedly elevated IOP (often >40 mmHg), corneal edema, conjunctival hyperemia, and fixed mid-dilated pupil. 1, 4
• Requires immediate IOP-lowering therapy and emergent ophthalmology consultation. 3, 4
• Can cause irreversible optic nerve damage within hours. 2

Bilateral Orbital Cellulitis

• Characterized by periorbital soft tissue swelling, restricted eye movement, proptosis, and systemic signs of infection. 1
• Requires immediate CT orbits with contrast and IV antibiotics. 1
• Bilateral presentation suggests severe systemic infection or cavernous sinus thrombosis. 1

Non-Emergent but Significant Conditions

Thyroid Eye Disease

• Bilateral proptosis with pressure sensation, lid retraction, and extraocular muscle enlargement. 1
• MRI or CT orbits demonstrates enlarged extraocular muscles (particularly inferior and medial recti) and increased orbital fat. 1
• May present with compressive optic neuropathy requiring urgent decompression. 1

Idiopathic Orbital Inflammatory Syndrome (IOIS)

• Can present bilaterally with orbital pain, pressure, and restricted motility. 1
• MRI shows inflammatory enhancement of orbital structures; chronic forms demonstrate T2 hypointensity from fibrosis. 1
• Responds to corticosteroid therapy. 1

Bilateral Optic Neuritis

• Painful eye movements with vision loss, though bilateral simultaneous presentation is uncommon in multiple sclerosis. 1
• More typical of neuromyelitis optica spectrum disorder. 1
• MRI orbits and brain with contrast shows optic nerve enhancement and demyelinating lesions. 1

Dry Eye Syndrome

• Burning, stinging, foreign body sensation with symptoms disproportionate to clinical signs. 3
• Exacerbated by wind, low humidity, prolonged visual tasks, and worsens later in the day. 3
• Managed with ocular lubricants and anti-inflammatory therapy. 3

Neuropathic Corneal Pain

• Symptoms dramatically outweigh clinical examination findings. 3
• Proparacaine challenge test differentiates peripheral (complete relief) from central sensitization (no relief). 3
• Requires topical nerve regenerative therapies or oral neuromodulators. 3

Critical Examination Components Required

Immediate Assessment

• Visual acuity testing in each eye as baseline measurement. 3
• Pupil examination for size, shape, reactivity, and relative afferent pupillary defect. 1, 3, 5
• Intraocular pressure measurement by Goldmann applanation tonometry in both eyes. 1, 3
• Gonioscopy in dark room with narrow beam to assess iridotrabecular contact and peripheral anterior synechiae. 1, 2

Slit-Lamp Biomicroscopy

• Assess anterior chamber depth centrally and peripherally. 1
• Examine for corneal edema (microcystic or stromal), conjunctival hyperemia, iris abnormalities, and lens position. 1
• Fluorescein staining to evaluate corneal epithelial integrity. 3

Fundoscopic Examination

• Evaluate optic disc for papilledema, cupping, or pallor. 5
• Assess for venous engorgement suggesting increased intracranial pressure. 5

Algorithmic Approach to Bilateral Eye Pain and Pressure

Step 1: Identify Red Flags Requiring Emergency Intervention

• If mid-dilated or poorly reactive pupils present → measure IOP immediately and refer urgently to ophthalmology for suspected angle closure. 1, 3, 2
• If IOP >21 mmHg with symptoms → perform gonioscopy to confirm iridotrabecular contact. 1, 2
• If proptosis with restricted motility and fever → obtain CT orbits with contrast emergently for orbital cellulitis. 1
• If papilledema on fundoscopy → obtain MRI brain with contrast and refer urgently for increased intracranial pressure. 5

Step 2: Confirm or Exclude Angle-Closure Disease

• Gonioscopy is mandatory in all patients with bilateral eye pressure and pain to detect occludable angles. 1, 2
• Compression gonioscopy differentiates appositional from synechial closure. 1
• If iridotrabecular contact confirmed → laser peripheral iridotomy in both eyes is definitive treatment. 2

Step 3: Assess for Inflammatory or Infiltrative Orbital Disease

• If proptosis without infection signs → MRI orbits without and with contrast to characterize orbital masses or thyroid eye disease. 1
• If bilateral orbital inflammation suspected → MRI or CT orbits; no consensus on superiority. 1

Step 4: Evaluate for Ocular Surface or Neuropathic Pain

• If symptoms exceed clinical signs → consider neuropathic corneal pain and perform proparacaine challenge test. 3
• If dry eye suspected → assess tear break-up time and Schirmer testing. 3

Critical Pitfalls to Avoid

• Never dismiss transient symptoms as benign—these represent warning episodes before potentially blinding acute attacks. 3, 2
• Do not delay fellow eye prophylaxis after treating one eye for angle closure; acute attacks can occur within days. 2
• Avoid pupil dilation until after iridotomy is performed in patients with suspected occludable angles, as dilation can precipitate acute crisis. 2
• Do not initiate treatment before establishing diagnosis in patients with blurred vision, pain, and photophobia—particularly for infectious keratitis. 3
• Never perform gonioscopy with bright light passing through the pupil, as this induces miosis and artificially widens the angle. 1

Urgent Ophthalmology Referral Indications

• Elevated IOP with symptoms (18% blindness risk, 48% glaucomatous neuropathy risk within 4-10 years if untreated). 3, 2
• Mid-dilated, poorly reactive, or oval pupil. 1, 3
• Vision changes, severe photophobia, or corneal opacity. 3
• Papilledema on fundoscopy. 5
• Suspected uveitis with anterior chamber cells. 5

Imaging Recommendations When Indicated

• MRI orbits without and with contrast for suspected orbital mass, optic nerve pathology, or inflammatory disease. 1
• CT orbits with contrast for suspected orbital cellulitis or when assessing bony anatomy for surgical planning. 1
• MRI brain with and without contrast if intracranial extension, demyelination, or increased intracranial pressure suspected. 1, 5