What should an elderly man with left eye pain and blurred vision do?

Immediate Ophthalmologic Evaluation Required

An elderly man with left eye pain and blurred vision requires immediate ophthalmologic evaluation to exclude vision-threatening emergencies, particularly acute angle-closure glaucoma, which can cause permanent blindness if diagnosis is delayed. 1

Critical Initial Assessment

The patient needs urgent measurement of:

• Visual acuity as baseline documentation 1
• Intraocular pressure (IOP) to detect elevated pressure suggesting acute glaucoma 1, 2
• Pupil examination to assess for mid-dilated, poorly reactive pupil characteristic of angle-closure 1
• Slit-lamp biomicroscopy to evaluate anterior chamber depth and detect cells suggesting inflammation 1
• Gonioscopy to assess angle anatomy, though this may require specialized equipment 1

Most Likely Diagnoses to Exclude

Acute Angle-Closure Glaucoma

This is the most urgent diagnosis to rule out, as it presents with:

• Abrupt onset of unilateral painful red eye with blurred vision 2
• Constitutional symptoms (nausea, vomiting) may accompany ocular symptoms 2
• Elevated IOP confirms the diagnosis 2
• Requires emergency ophthalmologic intervention to reduce IOP before permanent retinal damage occurs 2, 3

Intermittent Angle-Closure Disease

• Presents with episodic eye pain that resolves spontaneously but can progress to acute crisis 1
• Risk factors include older age (relevant for this elderly patient) 1
• Standard examination between episodes may appear normal, requiring dark-room dynamic gonioscopy for diagnosis 1

Anterior Uveitis/Iritis

• Can present with intermittent episodes of pain, photophobia, and blurred vision 1
• Requires slit-lamp examination to detect anterior chamber cells 1
• Minimal external signs may be present between episodes 1

Neuropathic Ocular Pain

• Suspect when symptoms significantly outweigh clinical signs 1
• Characterized by burning, stinging, or aching quality with photophobia 1
• Diagnostic anesthetic challenge test can differentiate peripheral from central causes 1

Critical Pitfalls to Avoid

Do not initiate empiric treatment without establishing a diagnosis, as this can mask vision-threatening conditions like acute angle-closure glaucoma 1. Delaying diagnosis of acute angle-closure crisis results in permanent blindness in 18% of cases 1.

Do not assume the pain is benign simply because it may be intermittent or the eye appears relatively normal externally 1. Severe pain with minimal signs suggests neuropathic pain requiring different management than inflammatory or structural causes 1.

Immediate Referral Pathway

• Emergency department or ophthalmologist referral is mandatory for all patients with acute eye pain and vision changes 4, 3
• If acute angle-closure glaucoma is confirmed, urgent IOP reduction with medical management (high-dose steroids, mannitol, and/or acetazolamide) is required before definitive laser peripheral iridotomy 1
• Diagnosis and management require the training and clinical judgment of an experienced ophthalmologist 5

If Cranial Nerve Palsy Suspected

Should the ophthalmologic examination reveal diplopia with ocular misalignment suggesting cranial nerve involvement:

• In elderly patients with hypertension, hyperlipidemia, or diabetes, evaluation may be limited to blood pressure, serum glucose, and hemoglobin A1c if no temporal tenderness, jaw claudication, or scalp pain is present 5
• If scalp tenderness, jaw claudication, or pain is present, erythrocyte sedimentation rate and C-reactive protein should be checked immediately, with temporal artery biopsy if results suggest giant cell arteritis 5
• Neuroimaging should be considered if other cranial neuropathies, neurologic changes, or elevated IOP are present 5