From the Guidelines
For a 67-year-old female with a painful red eye, I recommend a comprehensive ophthalmic evaluation including visual acuity testing, slit lamp examination, intraocular pressure measurement, and fluorescein staining, as moderate or severe pain is a circumstance that requires evaluation by an ophthalmologist 1. The differential diagnosis should focus on acute angle-closure glaucoma, anterior uveitis, corneal abrasion, keratitis, and bacterial conjunctivitis. Specific tests should include:
- Pupillary response assessment to rule out acute angle-closure glaucoma, which presents with a mid-dilated pupil and elevated intraocular pressure
- Fluorescein staining to identify corneal epithelial defects suggesting abrasion or keratitis
- Cell and flare examination in the anterior chamber if anterior uveitis is suspected due to photophobia and circumcorneal redness
- Conjunctival swab for culture if bacterial conjunctivitis is suspected, before initiating antibiotics Additional diagnostics may include:
- Tear film evaluation for dry eye disease
- Eversion of the upper eyelid to check for foreign bodies Prompt diagnosis is crucial as conditions like acute angle-closure glaucoma require immediate intervention to prevent permanent vision loss, while infectious causes need appropriate antimicrobial therapy to prevent complications. The patient's symptoms and signs should be evaluated in the context of various types of conjunctivitis, including viral adenoviral, Epstein-Barr virus, Zika virus, and SARS-CoV-2/COVID-19, as these can present with similar symptoms 1.
From the Research
Suggested Diagnostics for Painful Red Eye
The patient's symptoms of a painful red eye may be indicative of an underlying condition that requires immediate attention.
- A detailed interrogation of the patient's medical history is essential to exclude other possible confounding disorders that present similarly, especially those originating in the CNS 2.
- Basic examination of the eye should include:
- Assessment of the anterior segment with a bright light
- Measurement of intraocular pressure
- A full neurological exam
- The patient's symptoms, such as sudden onset of red eye associated with pupillary dilation, dull pain, and headache, may suggest acute angle closure glaucoma, which should be excluded 2.
- Immediate treatment must be initiated whenever there is high clinical suspicion of acute angle closure, with the administration of systemic ocular hypotensive therapy to prevent damage to the optic nerve and limit visual loss 2.
- An urgent referral to the ophthalmologist is mandatory to dictate definitive management 2.