What is the appropriate management and differential diagnosis for a patient presenting with eye pain, considering their demographic and medical history?

Eye Pain: Differential Diagnosis and Management

Immediate Vision-Threatening Emergencies Requiring Urgent Action

Any patient presenting with eye pain combined with vision changes, severe photophobia, mid-dilated/poorly reactive pupil, or elevated intraocular pressure requires immediate ophthalmology referral to prevent permanent blindness. 1, 2

Acute Angle-Closure Glaucoma

• Bilateral transient episodes with halos around lights, opaque vision, and eye pain are pathognomonic for intermittent angle closure, carrying a 50% risk of acute crisis within 5 years if untreated. 1, 3
• Untreated eyes have an 18% risk of permanent blindness and 48% risk of glaucomatous optic neuropathy within 4-10 years. 3
• Critical examination findings include mid-dilated pupil, poor pupillary reactivity, or oval pupil shape during or after an attack. 1, 3
• Never dismiss transient symptoms as benign—they represent warning episodes before potentially blinding acute attacks. 3
• Definitive treatment is laser peripheral iridotomy for both eyes once gonioscopy confirms iridotrabecular contact. 3
• Do not delay fellow eye prophylaxis after treating one eye, as the disease is bilateral. 3

Infectious Keratitis

• Presents with severe pain, photophobia, and blurred vision. 1
• Demands immediate ophthalmologic consultation before any treatment initiation. 1
• Do not initiate treatment before establishing a diagnosis in patients with blurred vision, pain, and photophobia. 1

Orbital Cellulitis

• Characterized by periorbital soft tissue swelling, pain, and restricted eye movement. 1
• Requires immediate imaging and treatment per American College of Radiology guidelines. 1

Critical Examination Components Required for All Patients

Every patient with eye pain requires a systematic examination to identify vision-threatening conditions: 1, 2

1. Visual acuity testing as baseline for every patient 1
2. Pupil examination for reactivity, afferent defects, mid-dilation, or oval shape 1, 2
3. Intraocular pressure measurement by Goldmann applanation tonometry in both eyes 1, 2
4. Slit-lamp biomicroscopy of the anterior segment 1
5. Fluorescein staining for corneal integrity 1
6. Gonioscopy in a dark room with narrow beam if angle closure suspected to assess iridotrabecular contact 2, 3

Critical Pitfall

• Avoid fluorescein-anesthetic combination drops for tear break-up time assessment. 1
• Avoid pupil dilation until after iridotomy is performed in patients with suspected narrow angles, as dilation can precipitate acute angle-closure crisis. 3

Non-Emergent Inflammatory Conditions

Dry Eye Syndrome

• Presents with burning, stinging, foreign body sensation, photophobia, with symptoms worsening later in the day. 1
• Exacerbated by wind, air travel, low humidity, and prolonged visual tasks. 1
• Burning and stinging pain can be disproportionate to clinical signs. 1
• Manage with ocular lubricants and anti-inflammatory treatment per American Academy of Ophthalmology guidelines. 1
• Patients with severe ocular pain often have associated psychological and systemic pain conditions (fibromyalgia, depression, anxiety, migraine). 4
• Higher pain severity correlates with less responsiveness to artificial tears, lubricating ointment, steroid drops, cyclosporine 0.05%, autologous serum tears, hot compresses, lid hygiene, and punctal occlusion. 4

Episcleritis

• Usually responds to topical steroids or NSAIDs without systemic treatment. 1

Uveitis

• Bilateral, insidious onset may indicate systemic inflammatory disease association. 1
• Requires ophthalmology referral for slit-lamp confirmation and treatment with topical and potentially systemic steroids. 1

Neuropathic Corneal Pain (Commonly Misdiagnosed)

Neuropathic corneal pain is characterized by symptoms outweighing clinical signs and requires specific diagnostic testing and targeted treatment. 5, 1

Diagnostic Approach

• The proparacaine challenge test differentiates peripheral from central neuropathic pain: 5, 1
  • Complete relief = peripheral origin
  • No relief = central sensitization
  • Partial relief = mixed pathology (most common in clinical practice)
• In vivo confocal microscopy confirms corneal nerve damage showing decreased nerve density, increased tortuosity, and beading. 1

Underlying Causes

• Peripheral origin: ocular surgery, herpes zoster ophthalmicus 5
• Systemic origin: small-fiber polyneuropathy, fibromyalgia 5
• Additional causes: DED, infectious keratitis, recurrent erosions, radiation keratopathy, contact lens wear 5

Management

• Topical nerve regenerative therapies or oral neuromodulators for treatment. 1
• Combination therapy addressing multiple factors is essential. 1
• Bandage contact lenses and moisture goggles may decrease evaporation-induced symptoms. 5
• Important co-morbid conditions include anxiety, depression, and post-traumatic stress disorders. 5

Algorithmic Approach to Eye Pain

Follow this systematic approach for all patients presenting with eye pain: 2

1. Identify red flags requiring emergency intervention:

   • Vision changes
   • Severe photophobia
   • Mid-dilated, poorly reactive, or oval pupil
   • Elevated IOP
   • Corneal opacity
   • Papilledema on fundoscopy 1, 2

2. Confirm or exclude angle-closure disease:

   • Measure IOP in both eyes
   • Perform gonioscopy if IOP elevated or symptoms suggest intermittent angle closure
   • Urgent ophthalmology referral if confirmed 2, 3

3. Assess for inflammatory or infiltrative orbital disease:

   • Bilateral proptosis with pressure sensation, lid retraction, and extraocular muscle enlargement suggests thyroid eye disease
   • MRI or CT orbits for suspected orbital mass, optic nerve pathology, or inflammatory disease 2

4. Evaluate for ocular surface or neuropathic pain:

   • Fluorescein staining for corneal integrity
   • Proparacaine challenge test if neuropathic pain suspected
   • Consider dry eye syndrome if burning/stinging with minimal signs 1, 2

Special Populations

Pediatric Patients

• Eye pain in preschool children (ages 2-6) without red eye or obvious cause is usually functional (91% of cases). 6
• However, examination is essential to exclude unapparent causes and identify unrelated conditions requiring treatment (refractive error, amblyopia). 6
• Serious conditions in children range from corneal foreign body to amblyogenic and life-threatening conditions. 7

Common Pitfalls to Avoid

• Never dismiss transient symptoms as benign—they may represent warning episodes before potentially blinding acute attacks. 1, 3
• Do not delay fellow eye prophylaxis after treating one eye for angle closure. 1
• Do not initiate treatment before establishing a diagnosis in patients with blurred vision, pain, and photophobia. 1
• Recognize that inflammatory eye disease (conjunctivitis, blepharitis, keratitis, uveitis, dry eye, chalazion, scleritis) accounts for 69% of eye pain cases in ophthalmology clinics. 8
• Be aware that migraine is the predominant cause of eye pain in neurology clinics (51%), requiring collaboration between ophthalmology and neurology. 8