Evaluation of the Painful Eye

 


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Eye problems constitute 2% to 3% of all primary care and emergency department visits. Common eye conditions that can cause eye pain are conjunctivitis, corneal abrasion, and hordeolum, and some of the most serious eye conditions include acute angle-closure glaucoma, orbital cellulitis, and herpetic keratitis. The history should focus on vision changes, foreign body sensation, photophobia, and associated symptoms, such as headache. The physical examination includes an assessment of visual acuity and systematic evaluation of the conjunctiva, eyelids, sclera, cornea, pupil, anterior chamber, and anterior uvea. Further examination with fluorescein staining and tonometry is often necessary. Because eye pain can be the first sign of an ophthalmologic emergency, the physician should determine if referral is warranted. Specific conditions that require ophthalmology consultation include acute angle-closure glaucoma, optic neuritis, orbital cellulitis, scleritis, anterior uveitis, and infectious keratitis.

Eye problems constitute 2% to 3% of all primary care and emergency department visits.1,2 Conjunctivitis, corneal abrasion, and hordeolum account for more than 50% of eye problems.1,2  Disorders that cause eye pain can be divided by anatomic area, with most affecting the cornea. Because most conditions that cause eye pain are associated with ocular signs and symptoms, familiarity with the differential diagnosis allows clinicians to appropriately tailor the history and physical examination (Table 1320  and Table 211).

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

A detailed contact lens history is recommended in patients with suspected keratitis to assess for increased risk of bacterial or Acanthamoeba infection.

C

12, 21, 22

The kinetic red test combined with the static finger wiggle test is the most sensitive way to assess for a visual field deficit in the primary care setting.

C

26

Absence of photophobia on the penlight test makes uveitis or keratitis unlikely.

C

23, 34

The swinging flashlight test can detect relative afferent pupillary defects in conditions such as optic neuritis, although a negative test does not rule it out.

C

35, 36

Neuroimaging is not recommended in patients presenting with unilateral eye or facial pain, normal examination findings, and no history of findings suggestive of a specific diagnosis or pain syndrome.

C

37


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

A detailed contact lens history is recommended in patients with suspected keratitis to assess for increased risk of bacterial or Acanthamoeba infection.

C

12, 21, 22

The kinetic red test combined with the static finger wiggle test is the most sensitive way to assess for a visual field deficit in the primary care setting.

C

26

Absence of photophobia on the penlight test makes uveitis or keratitis unlikely.

C

23, 34

The swinging flashlight test can detect relative afferent pupillary defects in conditions such as optic neuritis, although a negative test does not rule it out.

C

35, 36

Neuroimaging is not recommended in patients presenting with unilateral eye or facial pain, normal examination findings, and no history of findings suggestive of a specific diagnosis or pain syndrome.

C

37


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

View/Print Table

Table 1.

Selected Differential Diagnosis of Eye Pain: Key Features and Management Options

DiagnosisKey featuresManagement options

Conjunctiva

Bacterial conjunctivitis

Erythema of the bulbar conjunctiva, purulent discharge with bilateral matting of eyelids, no itching; Neisseria gonorrhoeae infection has a hyperacute presentation with copious discharge, eye pain, and decreased vision

All broad-spectrum antibiotic eye drops are effective

Culture should be performed only in severe cases, if the patient wears contact lenses, or if initial treatment is ineffective

Viral conjunctivitis

Erythema of the palpebral or bulbar conjunctiva, serous discharge with mild to no itching; adenovirus infection accounts for up to 62% of cases

Supportive care with cold compresses, ocular antihistamines, and artificial tears

Sclera

Scleritis

Severe, boring eye pain that is worse with eye movement and radiates or causes headache; red eye with thin, bluish sclera on examination; decreased visual acuity

50% of cases are associated with rheumatologic disease

Nonsteroidal anti-inflammatory drugs: ibuprofen, 400 to 600 mg three times per day;

The Authors

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MATTHEW PFLIPSEN, MD, is associate residency director in the Department of Family Medicine at Tripler Army Medical Center, Honolulu, Hawaii. He is also an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md....

MARIAMA MASSAQUOI, MD, is a third-year resident in the Department of Family Medicine at Tripler Army Medical Center.

SUZANNE WOLF, DO, is a chief resident in the Department of Family Medicine at Tripler Army Medical Center.

Address correspondence to Matthew Pflipsen, MD, Tripler Army Medical Center, 1 Jarrett White Rd., Honolulu HI 96859 (e-mail: matthew.c.pflipsen.mil@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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