What is the best course of action for a 15-year-old experiencing photophobia (abnormal sensitivity to light) in the left eye that radiates to the temple?

Urgent Ophthalmologic Evaluation Required for Possible Uveitis or Acute Glaucoma

This 15-year-old requires immediate comprehensive ophthalmologic examination to rule out sight-threatening conditions, particularly anterior uveitis, acute angle-closure glaucoma, or other inflammatory/infectious processes that commonly present with unilateral photophobia and periorbital pain radiating to the temple.

Critical Initial Assessment

The combination of unilateral photophobia with temporal radiation in an adolescent is concerning for intraocular inflammation or elevated intraocular pressure rather than primary headache disorders. The examining physician must perform:

• Slit-lamp examination to assess for anterior chamber inflammation (cells and flare), keratic precipitates, or corneal pathology 1, 2
• Intraocular pressure measurement to exclude acute angle-closure glaucoma, which can present with photophobia and referred temporal pain 1
• Pupillary examination including assessment for afferent pupillary defect, which may indicate optic nerve involvement 3
• Dilated funduscopic examination to evaluate for posterior segment inflammation or optic nerve pathology 4
• Visual acuity testing in both eyes to detect any vision loss 4

Differential Diagnosis Priority

Primary Ocular Causes (Most Likely)

• Anterior uveitis (iritis): Classic presentation with unilateral photophobia, pain radiating to temple, and ciliary flush 1, 2
• Acute angle-closure glaucoma: Though less common in adolescents, presents with severe photophobia, eye pain, and headache 5
• Corneal pathology: Including keratitis, abrasion, or foreign body causing photophobia 1
• Ocular trauma: Even minor trauma can cause photophobia; history may reveal recent injury 6

Secondary Neurologic Causes

• Migraine headache: Most common cause of photophobia overall (53.7% in one series), but typically bilateral and associated with other migraine features 6
• Optic neuropathy: Can present with photophobia and requires urgent evaluation if suspected 3

Management Algorithm

If Anterior Segment Pathology Identified:

• Treat underlying cause (topical corticosteroids for uveitis, pressure-lowering agents for glaucoma, antibiotics for infectious keratitis) 1
• Tinted contact lenses or glasses can provide symptomatic relief for photophobia during treatment 3
• Consider colored glasses (blue, green, red, or purple) which provided relief in 85% of photophobic patients in one study 7

If Examination Normal:

• Consider migraine as primary diagnosis, particularly if bilateral symptoms develop or family history present 2, 6
• Implement conservative photophobia management: sunglasses, cap or visor, avoiding bright lights 3
• Trial of colored lenses for indoor use, as sunglasses are impractical in low-light settings 7

Critical Pitfalls to Avoid

• Do not dismiss unilateral photophobia as "just migraine" without thorough ocular examination, as 25.9% of photophobia patients (particularly 69.4% of children) leave clinics without documented diagnosis 6
• Do not use atropine for pain control in suspected ocular trauma, as this can worsen outcomes and obscure ongoing assessment 5
• Do not delay evaluation if visual acuity is decreased or pupillary defect present, as these suggest serious pathology requiring urgent intervention 3

Symptomatic Relief Strategies

While treating underlying cause:

• Reversing polarity (white text on black background) on electronic devices helps photophobic patients 3
• Positioning with back to windows reduces light exposure in indoor settings 3
• Empirical testing of colored glasses using penlight to elicit photophobia, then testing different colored lenses for optimal relief 7

Follow-Up Timing

• If inflammatory or infectious cause identified: 2-3 days to assess treatment response 4
• If migraine diagnosed: 2-4 weeks to evaluate headache pattern and photophobia improvement 2
• If no diagnosis established: 1-2 weeks for re-evaluation, as significant knowledge gap exists in diagnosing photophobia, particularly in children 6