A differential guide to 5 eye complaints
Here’s help identifying conditions you can’t afford to miss, including a handy mnemonic to ensure a comprehensive eye exam.
A full ophthalmologic evaluation is indicated to detect or rule out a retinal detachment or tear—which has been found to co-occur with acute vitreous detachment in 14% of cases.13 Those who present with decreased visual acuity or a visual field defect or describe a “curtain of darkness” are at risk for retinal detachment and require a same-day referral.13
Like patients with vitreous detachment, those with a retinal detachment will report new floaters or peripheral flashing lights.12 The presence of vitreous hemorrhage or pigment, which can be seen in a slit lamp exam, is associated with increased risk for retinal detachment, as is a subjective report of vision loss.13
When retinal detachment is suspected, immediate referral to an ophthalmologist is needed.13 Reattachment surgery has good outcomes, especially if it is performed prior to macular involvement or within the first 3 days of macular detachment.14
3) "My eye hurts and is red"
Patients with painful, red eyes are at risk for a variety of sight-threatening conditions, iritis (anterior uveitis), keratitis, and acute angle closure glaucoma, as well as eye trauma, among them (TABLE).1,2,4,12,15-27 Decreased visual acuity in a patient with painful, red eyes warrants an urgent or emergent ophthalmologic referral.
When to suspect iritis
Patients with iritis will complain of vision loss, pain, photophobia, and redness. An eye exam will reveal injection of the conjunctiva around the cornea. Visual acuity is often decreased. Pupillary reaction may be sluggish, and the pupil may be smaller or larger than the other eye,4 but a normal pupil size does not exclude iritis in a patient with unilateral eye pain and ciliary injection.15
Iritis is often idiopathic, but risk factors include chronic inflammatory conditions such as ankylosing spondylitis, ulcerative colitis, and Crohn’s disease.16
Treatment with topical steroids is recommended.16 Urgent referral for long-term management of iritis is needed.17
Keratitis has varied causes
Patients with keratitis present with eye pain or foreign body sensation, redness, blurred vision, and photophobia. Examination of the eye will show injection of the conjunctiva surrounding the cornea, and possible corneal defects or opacities; visual acuity may be normal or decreased. The cause varies, based on whether keratitis is bacterial, viral, or noninfectious.
Risk factors for bacterial keratitis include extended wear of contact lenses, eye trauma, eye surgery, and systemic disease such as diabetes mellitus, while viral keratitis often follows a case of viral conjunctivitis and herpes simplex keratitis often involves reactivation of the virus. Causes of noninfectious keratitis include flash burns, dry eye or blepharitis, snow blindness, and sunburn.18
Treatment with topical antibiotics is effective for bacterial keratitis, but follow-up referral is needed because the infection could lead to loss of sight.19 Herpes simplex keratitis, which may appear as a mild corneal ulcer (a slit lamp examination will show the classic branching dendritic lesion), can be managed with topical antiviral medications,20 but here, too, an ophthalmologic referral is recommended to look for deeper corneal infiltrates that could lead to vision loss.20,21 Topical numbing medications should not be prescribed for patients with eye problems, as their extended use can lead to infection, corneal thinning, or even perforation of the cornea.22
Blurred vision, pain suggest acute angle closure glaucoma
Patients with acute angle closure glaucoma present with blurred vision, deep eye pain or brow ache, and frequently, nausea and vomiting.23 Some patients report seeing halos around lights, as well.
Risk factors for acute angle closure glaucoma include older age, Asian descent, farsightedness, family history, and female sex. Attacks are commonly idiopathic, but some are associated with routine pupillary dilation during eye exams.24
On examination, the cornea will be cloudy due to edema and the pupil will be mid-dilated and fixed.12 Typically, intraocular pressure in the affected eye will be elevated, an indication that the nausea and vomiting are associated with this disorder rather than a gastrointestinal condition.23 Emergent referral is needed to preserve vision.25
Eye trauma: What you’ll see, when to act Hyphema. In patients with a hyphema—typically the result of eye trauma—you’ll usually see a meniscus of blood in front of the iris in the anterior chamber. If the patient was supine before the evaluation, however, you’ll see red discoloration of the iris. Hyphemas can be a threat to vision, mostly due to potential elevated pressure. Because they are often associated with more extensive ocular injuries that are not always immediately evident, urgent referral is required.26
Hyphema—What you'll see
