What is the most appropriate initial approach to a patient who reports a spot under the eye?

Initial Approach to a Patient Reporting a Spot Under the Eye

The most appropriate initial approach is to perform a focused assessment to differentiate between benign periorbital findings and vision-threatening conditions by evaluating visual acuity, assessing for red flag symptoms (pain, photophobia, vision changes), and performing external examination—with immediate ophthalmology referral if any concerning features are present. 1, 2

Immediate Red Flag Assessment

The first priority is to identify symptoms or signs requiring urgent ophthalmologic evaluation within 24 hours: 1, 2

• Visual symptoms: Any blurred vision, vision loss (even subtle or transient), or visual field changes mandate immediate referral 1, 2
• Pain: Moderate to severe eye pain suggests corneal involvement, elevated intraocular pressure, or inflammation requiring urgent evaluation 3, 1
• Photophobia: Light sensitivity may indicate corneal damage, anterior uveitis, or moderate to severe inflammation 3, 2
• Redness: Conjunctival injection, especially with discharge or ocular surface changes, requires immediate ophthalmology consultation 1, 2

Essential History Components

Obtain specific details that guide diagnosis and urgency: 3, 1

• Timing and pattern: Acute onset versus gradual development; diurnal variation (worse upon waking, improving later in day) suggests endothelial dysfunction with fluid accumulation 3, 1
• Laterality: Unilateral versus bilateral presentation—bilateral with systemic symptoms warrants workup for metabolic, hereditary, or medication-related causes 1
• Associated symptoms: Document presence or absence of discharge, tearing, foreign body sensation, or functional impairment 3, 2
• Recent trauma or surgery: Increases risk of infection, inflammation, or tissue breakdown 1
• Medication history: Amiodarone, rho kinase inhibitors, topical corticosteroids, and amantadine can cause periorbital changes 1

Physical Examination Priorities

Perform a targeted examination focusing on vision-threatening findings: 1, 2

• Visual acuity testing: Always measure and document at presentation 2, 4
• Pupil examination: Assess reactivity and check for afferent pupillary defects 2
• External inspection: Evaluate eyelid swelling, discoloration, proptosis, or restriction of eye movements (suggests preseptal/orbital cellulitis) 2
• Slit-lamp examination (if available): Assess corneal clarity and absence of infiltrates or ulcers—corneal involvement is a critical red flag 2, 4
• Discharge character: Document purulent, mucopurulent, or absence of discharge 4

Management Algorithm

If ANY red flags present (vision changes, pain, photophobia, redness, corneal involvement, purulent discharge): 1, 2

• Do not initiate treatment before ophthalmology evaluation
• Avoid empiric topical steroids, which can worsen infectious keratitis, mask severity, or elevate intraocular pressure 3, 2
• Refer immediately to ophthalmology within 24 hours 2

If NO red flags present (no pain, no vision changes, no functional impairment, complete resolution between episodes): 1

• Observation is sufficient with watchful waiting 1
• Provide symptomatic relief with preservative-free lubricants, warm compresses, and gentle lid hygiene 2
• Routine ophthalmology referral within 4 weeks if unresponsive to initial measures after 1 week 2

Critical Patient Counseling

Instruct patients to seek immediate care for: 1, 2

• New or worsening pain, redness, or light sensitivity 1
• Any vision changes, including blurring, glare, or visual field loss 1
• Increased discharge or ocular surface changes 1

Reassurance is appropriate when episodes completely resolve without intervention and no functional impairment occurs between episodes. 1

Common Pitfalls to Avoid

• Never dismiss visual symptoms as minor—even subtle or transient changes require ophthalmology evaluation 1, 2
• Never initiate corticosteroids empirically—this can worsen infectious causes and elevate intraocular pressure 3, 2
• Never assume benign etiology without documenting absence of red flags—preseptal/orbital cellulitis, keratitis, and anterior uveitis can present initially with seemingly minor periorbital findings 2