How should I evaluate and manage a 60-year-old woman presenting with acute eye pain?

Evaluation and Management of Acute Eye Pain in a 60-Year-Old Woman

This patient requires immediate ophthalmologic evaluation before any treatment is initiated, as eye pain can represent vision-threatening emergencies including acute angle-closure glaucoma, infectious keratitis, anterior uveitis, or scleritis. 1, 2

Immediate Referral Rationale

Delaying diagnosis of conditions like acute angle-closure crisis results in permanent blindness in 18% of cases and visual acuity worse than 20/40 in 58% of affected eyes. 1, 2 The presence of eye pain with associated symptoms such as blurred vision or photophobia indicates urgent anterior segment disease requiring specialist assessment to prevent severe visual morbidity. 2

Critical Diagnostic Components Required by Ophthalmology

The ophthalmologist must perform a comprehensive examination including: 1, 2

• Visual acuity testing as essential baseline measurement 1, 2
• Pupil examination to detect mid-dilated, poorly reactive, or oval pupil (suggesting acute angle-closure) or relative afferent pupillary defect (indicating optic nerve disease) 2
• Slit-lamp biomicroscopy to evaluate anterior chamber cells, corneal pathology, and conjunctival/scleral inflammation 1, 2
• Intraocular pressure measurement to rule out glaucoma 1, 2
• Gonioscopy to assess angle structures, particularly if intermittent angle closure is suspected 1
• Fluorescein staining to identify corneal epithelial defects 1

Most Critical Diagnoses to Exclude

Intermittent Angle-Closure Disease

This is the most critical diagnosis to exclude, as it presents with episodic eye pain that resolves spontaneously but can progress to acute angle-closure crisis. 1 Risk factors include Asian descent, hyperopia, older age (relevant for this 60-year-old patient), female gender, and short axial length. 1 Dark-room dynamic gonioscopy is essential because standard examination between episodes may appear completely normal. 1

Infectious Keratitis

Requires aggressive management including cultures and broad-spectrum antibiotics, as devastating vision loss can occur even with appropriate treatment. 3 Any corneal infection demands urgent specialist management. 3

Anterior Uveitis/Iritis

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

Scleritis

Represents a serious inflammatory condition requiring ophthalmology consultation and often systemic immunosuppressive therapy. 4, 5

Neuropathic Ocular Pain

Suspect this when symptoms significantly outweigh clinical signs and pain persists despite appropriate treatment of any ocular surface abnormalities. 1 Characteristic descriptors include burning, stinging, or aching quality with photophobia and wind sensitivity. 1 A diagnostic anesthetic challenge test can differentiate peripheral neuropathic pain (improves with anesthetic) from central causes (persistent pain). 1

Common Pitfalls to Avoid

Do not initiate empiric treatment without establishing a diagnosis, as this can mask vision-threatening conditions. 1 While mild external infections can be treated empirically in primary care, severe conjunctivitis and any corneal infection require aggressive management by an ophthalmologist. 3

Recognize that severe pain with minimal signs suggests neuropathic pain, which requires completely different management than inflammatory or structural causes. 1 This condition involves peripheral and central sensitization causing persistent pain perception even in the absence of ocular surface abnormalities. 6

Age-Specific Considerations

At 60 years old, this patient has increased risk for: 1

• Primary angle-closure disease (older age is a risk factor)
• Dry eye disease with secondary neuropathic pain 7
• Inflammatory conditions requiring systemic evaluation

Management Algorithm Based on Diagnosis

If Acute Angle-Closure Confirmed:

Laser peripheral iridotomy is the definitive treatment to relieve pupillary block, with prophylactic iridotomy indicated in the fellow eye. 1

If Neuropathic Ocular Pain Diagnosed:

Treatment includes autologous serum tears for peripheral component, oral neuromodulators (such as nortriptyline starting at 10-25 mg at bedtime, increased to 25-100 mg as tolerated) for central component, and transcutaneous electrical nerve stimulation or periorbital botulinum toxin A for photophobia/headache. 7, 1

If Anterior Uveitis Confirmed:

Topical prednisolone acetate 1% is preferred over difluprednate, with systemic immunomodulatory therapy required for chronic or recurrent cases. 1

If Ocular Surface Disease with Inflammation:

Topical loteprednol is first-line anti-inflammatory therapy, with preservative-free formulations (such as compounded methylprednisolone 1%) recommended for patients with severe hyperalgesia. 7 Lifitegrast 5% is FDA-approved for signs and symptoms of dry eye disease. 7