Differential Diagnosis for Eye Pain and Soreness
The patient's symptoms of feeling like something hit their eye and experiencing soreness in the lower eye, without evidence of an ulcer or abrasion on fluorescein exam, suggest several potential diagnoses. These can be categorized as follows:
Single Most Likely Diagnosis
- Subconjunctival Hemorrhage: This condition occurs when a small blood vessel breaks beneath the conjunctiva, the clear surface of the eye. It can cause the sensation of something hitting the eye and is often associated with pain or soreness. The absence of an ulcer or abrasion on fluorescein exam supports this diagnosis, as subconjunctival hemorrhages do not affect the corneal surface.
Other Likely Diagnoses
- Corneal Foreign Body: Even though the fluorescein exam did not show an ulcer or abrasion, a small foreign body could still be lodged in the cornea, causing discomfort and the sensation of something being in the eye. It's possible that the foreign body is not causing a significant enough defect to be visualized with fluorescein.
- Conjunctivitis: Inflammation of the conjunctiva can cause eye soreness and a feeling of grittiness or foreign body sensation, even in the absence of visible abrasions or ulcers.
Do Not Miss Diagnoses
- Angle-Closure Glaucoma: Although less common, this condition is an emergency. It can present with severe eye pain, blurred vision, and sometimes the sensation of a foreign body in the eye. The absence of an ulcer or abrasion does not rule out glaucoma, and missing this diagnosis could lead to permanent vision loss.
- Retinal Detachment: Symptoms can include sudden flashes of light and floaters, but in some cases, patients might describe a sensation similar to something hitting their eye. This is a medical emergency requiring immediate attention to preserve vision.
Rare Diagnoses
- Scleritis: Inflammation of the sclera, the white part of the eye, can cause severe eye pain and tenderness. It's less common than other conditions but should be considered, especially if the patient has a history of autoimmune disorders.
- Uveitis: Inflammation of the uvea, the middle layer of the eye, can cause eye pain, sensitivity to light, and vision problems. It's a rare condition but important to diagnose and treat to prevent complications.
Given these diagnoses, the initial management should include:
- A thorough eye examination, including a slit-lamp examination to look for any signs of foreign bodies, inflammation, or other abnormalities not visible on initial assessment.
- Consideration of further diagnostic tests, such as intraocular pressure measurement to rule out glaucoma, and potentially a dilated fundus examination to check for retinal detachment.
- Symptomatic treatment, such as lubricating eye drops for comfort, and possibly anti-inflammatory medications if an inflammatory condition is suspected.
- Urgent referral to an ophthalmologist if any of the "Do Not Miss" diagnoses are suspected.