painful eye

8/6/2019 Painful Eye

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The Painful But Not Red EyeDavid C. Fiore, M.D. , FAAFP

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The material presented at this activity is being made available by t he American Academy of FamilyPhysicians for educational purposes only. This material is not intended to represent the only, nornecessarily best, method or procedure appropriate for the medical situations discussed but, rather, isintended to present an approach, view, statement or opinion of the faculty that may be helpful to otherswho face similar situations.

The AAFP disclaims any and all liability for injury or other damages resulting to any individual attendingthis program and for all claims that may arise out of the use of the techniques demonstrated therein bysuch individuals, whether these claims shall be asserted by a physician or any other person. Everyeffort has been made to ensure the accuracy of the data presented at these activities. Physicians maycare to check specific details such as drug doses and contraindications, etc. in standard sources prior toclinical application. These materials have been produced solely for the education of attendees. Any useof content or the name of the speaker or AAFP is prohibited without written consent of the AAFP.

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David C. Fiore, M.D. , FAAFP, returned a disclosure indicating that he has no affiliation or financial interest in any organization(s).

Discuss causes of a painful quiet eye

Identify dangerous causes of the painful quiet eye

Discuss how to manage common causes of the painful quiet eye

1) Lee AG, Brazis PW. The evaluation of eye pain with a normal ocular exam.

SemOphth.2003 ; 18(4): 190-199.

2) Friedman DI. The eye and headache. Ophth Gun NAm. 2004;17(3):357-369.

3) Brazis PW, Lee AG, Stewart M, Capobianco D. Clinical review: The differential

diagnosis of pain in the quiet eye. The neurologist. 2002;8:82-l00.

Learning Objectives/

Search References

The Painful Quiet Eye

• History

– Location

– Intensity and character

– Vision loss.

• Physical exam

– Neurologic

– Visual acuity

– Visual field screen

– Tonometry

Ocular Conditions

• Narrow angle Glaucoma

• Cornea Diseases

• Scleritis and Episcleritis• Uvietis

• Optic Neuritis

• Dry Eye

Narrow Angle Glaucoma

– Most common acute vision threatening condition ageover 40 y.o.

– Headache (eye pain), vision loss, nausea/vomiting

– Narrow anterior chamber

– Anticholinergics, sympathomemetics, dim lighting – Acute Rx

• Cholinergics (pilocarbine)

• Beta-blocker (timilol)

• Prostaglandin analog (latanoprost)

• Oral carbonic anhydrase inhibitor (acetazolamide)



Corneal Diseases

• Usually a Red Eye

• Consider – Abrasion or foreign body

• Symptomatic Rx

• Consider topical antibiotics

• No patching

– Keratitis

• Rarely a “quiet” eye

• Refer to Ophtho

Scleritis and Episcleritis

• Episcleritis and anterior scleritis

cause a red eye• Posterior Scleritis

– Very rare

– Hard to diagnos

– Painful, tender eye, pain with eyemovement

– Referal

Intraocular Tumors

• Rarely cause eye pain

• Orbital extension may impinge onthe trigeminal nerve

• Primary tumors: choroidal

melanoma

• Metastatic – breast, lung, GI

Optic Neuropathy

• Classic Triad

– Decreased visual acuity

– Decreased color vision

– eye pain

• Age Dependent Likely Cause

– <40 – Demyelenating Dz (MS)

– >40 – Giant Cell Arteritis

Dry Eye

• Often FB sensation

• Causes

– Medications

• antihistamines, clonidine, beta blockers, NSAIDs, and

scopolamine

– Systemic Diseases

• keratoconjunctivitis sicca, Sjogren’s syndrome, RA

• Diagnosis

• Schirmer and Jones Tests

• Treatment

• Artificial Tears

• Treat underlying Cause

Orbital Conditions

• Inflammation, Infection, Tumor

• Findings

– Optic neuropathy, limitation or pain with

ocular movement, diplobia, proptosis,

enophthalmos, gaze evoked amaurosis

or facial pain and paresthesia

– Symptoms with straining suggest a

vascular cause

– CT or MRI aid diagnosis

• Prompt referral



CRANIAL CONDITIONS

• Cavernous Sinus Disease

– may affect CN III, the ophth. branch

of CN V• Paranasal Sinus Disease

• Sphenoid Dz – Surgical Urgency

• Tolosa-Hunt Syndrome

– idiopathic inflammatory granulomatous

condition of the cavernous sinus,

presents with eye and facial pain

– Resolves with steroid Rx (diagnostic)

NEUROLOGIC CONDITIONS

• Cluster Headache

• Migraine Headache• Trigeminal Neuralgia

• Elevated Intracranial Pressure

Cluster Headache.

• Most common in younger men

• Series (clusters) of attacks

– Minutes to hours

– Behind eye

– Associated with lacrimation andrhinitis

– Occassional Horner’s Syndrome

• Treatment

– Triptans

– Oxygen (?)

Migraine Headache

• Uncommonly presents as “eye

pain”

• Treat as “regular migraine”• Aukerman American Family Physician

December, 2002

Trigeminal neuralgia

• Ophthalmic branch rarely solely

affected

• Frequent sudden, severe attacks

• Treatment challenging

– Krafft American Family Physician May,

2008.

Elevated Intracranial Pressure

• Rarely just eye pain

• Exacerbated by coughing, valsalva

• Etiologies – Cerebral aneurysm, brain tumors, other

mass lesions, venous sinus thrombosis,

pseudotumor cerebri

• Treatment

– Underlying causes

– Neurosurgery



VASCULAR CONDITIONS

• TIA/CVA

• Carotid Artery Disease• Giant Cell Arteritis

Intracranial Bleeds and clots

• Subdural, epidural, subarachnoid,

intracerebral bleeds, TIA/CVA• One quarter of patients with

internal or middle cerebral CVA willhave eye or frontal head pain

• Imaging

– CT or MRI

Giant Cell arteritis

• Usually tenderness over temples

• Age usually >50

• May produce eye pain secondaryto orbital ischemia

– Usually vision loss

• Elevated ESR

• Prompt Rx with steroids

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painful eye

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