What are the recommendations for a patient with 2 weeks of left eye pain, foreign body sensation, and preauricular (in front of the ear) burning sensation, without discharge, redness, or blurred vision?

Urgent Ophthalmology Referral Required Within 24-48 Hours

This patient requires prompt ophthalmology evaluation within 24-48 hours due to persistent symptoms lasting 2 weeks with preauricular pain, which raises concern for viral keratoconjunctivitis, corneal foreign body with complications, or early infectious keratitis. 1, 2, 3

Immediate Assessment Priorities

Critical Red Flags to Evaluate Now

• Visual acuity testing is mandatory to establish baseline function and identify any vision loss requiring urgent same-day referral 2, 3
• Fluorescein staining should be performed to identify corneal epithelial defects, retained foreign body, or corneal infiltrate 2, 3
• Evert the upper eyelid to inspect for retained foreign body on the tarsal conjunctiva, as this commonly causes persistent foreign body sensation 3
• Examine for preauricular lymphadenopathy - the combination of foreign body sensation with preauricular burning/pain suggests viral conjunctivitis (particularly adenoviral) or HSV keratitis 1

High-Risk Features Requiring Same-Day Ophthalmology Referral

• Any corneal infiltrate, ulceration, or opacity 1, 3
• Corneal haze or purulent discharge 3
• Anterior chamber cells or hypopyon 1
• Irregular pupil 2, 3
• Vision loss or significant photophobia 3, 4

Most Likely Diagnoses Given This Presentation

Viral Keratoconjunctivitis (Most Concerning)

The 2-week duration with preauricular pain strongly suggests adenoviral or HSV infection rather than simple foreign body. 1

• Adenoviral conjunctivitis presents with foreign body sensation, preauricular lymphadenopathy, and can progress to punctate epithelial keratitis evolving to subepithelial infiltrates 1
• Symptoms typically last 5-14 days but can persist longer with corneal involvement 1
• The "stuck feeling" upon waking may represent epithelial irregularity from viral keratitis 1

HSV Keratitis (Cannot Miss)

• Usually unilateral with foreign body sensation, watery discharge, and palpable preauricular node 1
• Can present without classic dendritic lesions initially 1
• Requires antiviral therapy to prevent serious sequelae including stromal keratitis, scarring, and perforation 1

Retained Corneal Foreign Body

• The history of folding clothes suggests possible textile fiber or debris 2, 3
• Persistent symptoms beyond 48 hours after presumed foreign body exposure mandate ophthalmology evaluation 2, 3
• Risk of rust ring formation if metallic, or secondary infection 3

Immediate Management Before Ophthalmology Evaluation

Do NOT Initiate These Without Examination

• Do not prescribe topical antibiotics empirically without fluorescein examination, as this may mask infectious keratitis and delay appropriate treatment 1
• Do not use topical corticosteroids - these are contraindicated in HSV, fungal, and Acanthamoeba infections and can cause devastating complications 1
• Do not patch the eye - this increases risk of bacterial keratitis 1

Appropriate Temporizing Measures

• Artificial tears for symptomatic relief (preservative-free if using >4 times daily) 5
• Oral acetaminophen or NSAIDs for pain control 2, 3
• Avoid contact lens wear if applicable until evaluated 3

Critical Pitfalls to Avoid

The "Stuck Feeling" Upon Waking Is Significant

• This diurnal pattern suggests corneal epithelial irregularity or edema from endothelial dysfunction 1
• Transient blurring upon waking that improves later in the day indicates corneal edema that resolves with evaporation 1
• This patient denies blurred vision, but the stuck sensation may represent early epithelial disease 1

Preauricular Pain Changes the Differential Dramatically

• Preauricular lymphadenopathy with burning sensation is a hallmark of viral conjunctivitis (especially adenoviral and HSV) 1
• This is NOT typical of simple foreign body or dry eye 1
• The 2-week duration makes bacterial conjunctivitis unlikely (typically self-limited in 5-7 days) 1

Duration Matters

• Symptoms persisting beyond 1 week require ophthalmology evaluation to rule out infectious keratitis, retained foreign body, or viral keratitis with corneal involvement 1, 2, 3
• Chronic inflammation can lead to corneal scarring and permanent vision loss if untreated 1

Specific Instructions for Ophthalmology Referral

When referring, communicate:

• Visual acuity measurement 2, 3
• Mechanism of injury (folding clothes) and timeline (2 weeks) 2, 3
• Presence of preauricular pain/lymphadenopathy 1
• Results of fluorescein examination if performed 2, 3
• Absence of discharge, redness, or blurred vision (atypical features) 3

Patient Warning Signs for Immediate Return

Instruct patient to return immediately or go to emergency department if:

• Worsening pain or new vision changes 3
• Development of discharge or increasing redness 3
• New photophobia or light sensitivity 4, 6
• Eye pain not relieved with oral analgesics 5