What is the recommended comprehensive eye examination and differential diagnosis for a patient presenting with ocular symptoms?

Comprehensive Eye Examination and Differential Diagnosis

A comprehensive adult eye examination must include visual acuity testing, pupillary assessment, intraocular pressure measurement, slit-lamp biomicroscopy, and dilated fundus examination to detect vision-threatening conditions, with the history being critical as physical examination alone contributes to diagnosis in only 12% of cases. 1, 2

Essential History Components

The history is paramount and should systematically address:

• Chief complaint with temporal characteristics: Sudden onset (hours to days) suggests angle-closure glaucoma, anterior uveitis, or infectious keratitis, while gradual onset (weeks to months) indicates corneal edema or neuropathic pain 2
• Visual symptoms: Blurred vision worse in morning suggests corneal edema; persistent blurring indicates corneal opacification 2
• Ocular symptoms: Document photophobia (suggests uveitis, keratitis, or neuropathic pain), diplopia (requires urgent neurologic evaluation), pain quality (burning/shooting suggests neuropathic pain), and redness 1, 2
• Past ocular history: Previous surgery (refractive, cataract) increases risk of post-surgical neuropathic pain; trauma can cause Descemet's membrane rupture 1, 2
• Systemic conditions: Diabetes, hypertension, autoimmune diseases (rheumatoid arthritis can cause scleritis/uveitis), and neurologic conditions 1, 2
• Medications: Current ophthalmic and systemic medications, including supplements 1
• Family history: Glaucoma (2.5-3.0 fold increased risk with positive family history), age-related macular degeneration (4-fold increased risk), and other hereditary conditions 1, 3
• Social history: Smoking (increases AMD and cataract progression risk), occupation, and functional impact on daily activities 1

Core Physical Examination Elements

Visual Function Assessment

• Visual acuity at distance and near with current correction (record power of correction); refraction when indicated 1
• Visual fields by confrontation to detect cerebrovascular accidents or chiasmal tumors 1

External and Anterior Segment Examination

• External examination: Eyelid position/character, lacrimal apparatus, tear function, globe position, facial features (orbital tumors, Graves' disease) 1
• Pupillary function: Size, light response, relative afferent pupillary defect (Horner's syndrome, aneurysm, midbrain tumor) 1
• Ocular alignment and motility: Cover/uncover test, versions, ductions (myasthenia gravis, multiple sclerosis, Graves' disease) 1
• Slit-lamp biomicroscopy: Eyelid margins, tear film, conjunctiva, sclera, cornea, anterior chamber depth assessment, iris, lens, anterior vitreous 1

Intraocular Pressure and Posterior Segment

• Intraocular pressure measurement with contact applanation (Goldmann tonometry preferred); defer in suspected infection or corneal trauma 1
• Dilated fundus examination: Mid and posterior vitreous, retina (posterior pole and periphery), vasculature, optic nerve—critical as fundus examination has 79% sensitivity and 82% specificity for detecting eye disease 1, 4

Additional Testing When Indicated

Based on history and findings, consider:

• Gonioscopy for narrow angles or suspected angle-closure (intermittent pain with spontaneous resolution is pathognomonic of intermittent angle closure with 18% risk of permanent blindness) 1, 2
• Optical coherence tomography for retinal or optic nerve pathology 1
• Visual field testing (automated perimetry has 70% sensitivity for glaucoma) 1, 3
• Corneal topography/pachymetry for corneal disease 1
• Fluorescein angiography or OCT angiography for retinal vascular disease 1

Key Differential Diagnoses by Presentation

Acute Pain with Red Eye

• Angle-closure glaucoma: Intermittent pain with spontaneous resolution, Asian ethnicity, hypermetropia, advanced age risk factors 2
• Anterior uveitis: Photophobia, ciliary flush, cells/flare in anterior chamber 1, 2
• Infectious keratitis: Corneal infiltrate, epithelial defect 2

Gradual Vision Loss

• Cataract: Leading cause of treatable blindness in African Americans over 40; accounts for 50% of low vision in adults over 40 1
• Glaucoma: Prevalence 1-3% in Caucasians, 4.2-8.8% in African descent populations; 50% undiagnosed; increases 7% per year after age 40 1, 3
• Age-related macular degeneration: Leading cause of blindness in developed countries; prevalence 1% at age 55,15% at age 80+ 1, 3

Neurologic Signs

• Miller Fisher syndrome: Ophthalmoplegia, ataxia, areflexia—requires immediate hospitalization 5
• Myasthenia gravis: Variable ptosis, diplopia, fatigable weakness 5
• Compressive lesions: Diplopia, visual field defects, pupillary abnormalities 1, 2

Chronic Pain with Minimal Signs

• Ocular neuropathic pain: Burning/shooting pain with photophobia, symptoms exceed signs, persistence despite treatment of surface abnormalities, associated with fibromyalgia, depression, anxiety, migraine 2

Critical Pitfalls to Avoid

• Never attribute absent brainstem reflexes with dry conjunctivae to simple dry eye—this indicates serious neurological pathology requiring urgent evaluation 5
• Do not miss intermittent angle closure—intermittent pain with spontaneous resolution requires urgent gonioscopy to prevent acute attack and permanent blindness 2
• Do not rely on tonometry alone for glaucoma screening—sensitivity is only 27%; requires optic disc assessment and visual field testing 4, 3
• Do not miss lagophthalmos or exposure keratopathy—can lead to corneal ulceration and vision loss 5
• Recognize that persistence of symptoms despite appropriate treatment strongly suggests neuropathic pain rather than ongoing structural disease 2