What is the appropriate management for a patient with persistent eye pain and photophobia for over 3 weeks, with unremarkable complete blood count (CBC) and comprehensive metabolic panel (CMP)?

Management of Persistent Eye Pain and Photophobia

This patient requires urgent ophthalmologic evaluation within 24-48 hours to rule out sight-threatening uveitis, which is the most critical diagnosis to exclude given the combination of persistent eye pain and photophobia lasting over 3 weeks. 1

Immediate Diagnostic Approach

The priority is distinguishing between anterior segment inflammation (uveitis, episcleritis, keratitis) and other causes, as this directly impacts vision preservation:

Critical Red Flags Requiring Same-Day Ophthalmology Referral

• Eye pain with photophobia persisting beyond 2-3 weeks suggests inflammatory pathology rather than self-limited viral conjunctivitis 2
• Visual acuity must be assessed immediately - any vision worse than 20/40 mandates urgent specialist evaluation 2
• Slit-lamp examination is essential to identify anterior chamber inflammation, corneal pathology, or posterior segment involvement 1

Most Likely Diagnoses to Exclude

Acute Anterior Uveitis is the primary concern given the symptom duration and severity:

• Presents with eye pain, photophobia, and blurred vision 2, 1
• Can progress to vision loss if untreated 2
• Requires immediate initiation of topical prednisolone acetate 1% every 1-2 hours plus cycloplegic agents (cyclopentolate 1% or atropine 1%) 1
• Follow-up examination needed every 1-2 weeks during active inflammation 1

Infectious Keratitis must be ruled out:

• Patients should contact ophthalmology immediately if experiencing redness, pain, or increased photophobia 2
• Risk factors include contact lens wear, ocular surface disease, or recent trauma 2
• Requires topical antibiotic therapy if confirmed 2

Corneal Subepithelial Infiltrates (post-viral):

• Typically occur 1+ weeks after viral conjunctivitis onset 2
• When causing photophobia and decreased vision, topical corticosteroids at minimum effective dose are indicated 2
• Requires slow taper and regular IOP monitoring 2

Management Algorithm

Step 1: Ophthalmologic Examination (Within 24-48 Hours)

• Visual acuity measurement 1
• Slit-lamp biomicroscopy to assess anterior chamber, cornea, and conjunctiva 1
• Intraocular pressure measurement 2
• Pupillary examination with dilation if needed 2

Step 2: Treatment Based on Findings

If Uveitis Confirmed:

• Start topical prednisolone acetate 1% every 1-2 hours initially 1
• Add cycloplegic agent (cyclopentolate 1% or atropine 1%) to prevent posterior synechiae 1
• Consider systemic workup for underlying causes (HLA-B27, sarcoidosis, etc.) 2
• If recurrent or refractory, TNF inhibitors (adalimumab, infliximab) should be considered 1

If Episcleritis Confirmed:

• Topical corticosteroids are typically effective 2
• Artificial tears and cycloplegic agents as adjuncts 2
• Rarely requires systemic steroids 2
• Can continue with close monitoring 2

If Corneal Pathology:

• Infectious keratitis requires topical antibiotics (fluoroquinolones for contact lens wearers) 2
• Post-viral infiltrates with symptoms warrant topical corticosteroids (fluorometholone, loteprednol, or rimexolone preferred to minimize IOP elevation) 2

Step 3: Follow-Up Monitoring

• Weekly re-evaluation during active inflammation 1
• IOP checks with any corticosteroid use to monitor for steroid-induced glaucoma 2
• Taper corticosteroids slowly once inflammation controlled 2, 1

Common Pitfalls to Avoid

• Do not empirically treat with corticosteroids before ruling out infection - steroids can worsen infectious keratitis and prolong viral shedding 2
• Do not dismiss photophobia as benign - 25.9% of photophobia patients leave clinics without diagnosis, representing a significant knowledge gap 3
• Do not use bandage contact lenses without prophylactic antibiotics - infectious keratitis risk is substantial 2
• Avoid prostaglandin analogue glaucoma medications if inflammation is suspected, as they can worsen inflammation 2

Alternative Diagnoses if Ophthalmologic Exam Normal

If comprehensive eye examination reveals no anterior or posterior segment pathology:

• Migraine-associated photophobia is the most common cause (53.7% of photophobia cases) 3
• Dry eye syndrome accounts for 36.1% of photophobia presentations 3
• Rare neurologic causes (chiasmal compression, traumatic brain injury) should be considered only after thorough ophthalmologic evaluation 4, 5, 6

The unremarkable CBC and CMP effectively rule out systemic inflammatory or metabolic causes but do not exclude sight-threatening ocular pathology requiring immediate specialist evaluation. 2