Eye pain - red flag symptoms

By Dr Pipin Singh on the 1 September 2021

Dr Pipin Singh discusses the red flag symptoms in patients presenting with eye pain.

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Red flag symptoms

Sudden onset
Visual loss
Photophobia
Fever
Recent trauma
Vomiting
Associated red eye
Contact lens wearer
History of malignancy
History of flashers or floaters

History

A focused history and examination will often reveal the aetiology during your consultation. Explore the patient’s ideas, fears and expectations around their symptom, and why they have chosen to present now. A lot of patients will have researched their symptoms prior to presenting.

Questions to ask

Consider asking the following questions:

Where is the pain? How long has it been present?
Is it unilateral or bilateral?
Did the pain develop suddenly or over time? If suddenly, what were they doing at the time?
Has there been any reduced vision? If so, explore this further.
Have they noticed any associated blurred vision or double vision? Clarify what the patient means by blurred vision if they mention this symptom.
Have they noticed any flashers or floaters?
Has there been any recent preceding trauma?
Have they noticed any redness to the sclera?
Has there been associated photophobia?
Has there been any stickiness or grittiness?
Have they noticed any redness around the eye and if so, is this redness spreading? Does the surrounding skin look red or feel warm?
Is the patient a contact lens wearer?
Is there a history of migraine and if so, does it feel the same as previous headaches?
Does the eye water?
Is the pain getting worse? Are they systemically unwell?
Have there been any recent coughs or colds? Is there any nasal discharge?
Is there any scalp tenderness or jaw claudication?
Is there any history of malignancy?
Have they experienced this symptom before and if so, was there a diagnosis attributed to it?
Have they seen an optician regarding this specific symptom?
Is there any history of ophthalmological problems? If so, what was the diagnosis?
How is the symptom affecting function? Check on employment status. Their work may be related to the problem, for example if there is a foreign body in the eye.
Do they drive?

Examination: remote

If you are examining the patient remotely, via telephone or video, you could ask them to send a photograph of both eyes (or show you on the camera) to allow you to compare the 'bad' eye with the 'good' eye.

Consider how the eye looks. Is there any obvious redness, any lumps, bumps or discharge? It maybe difficult to assess the pupil and undertake any further examination, particularly if you are consulting by telephone.

You might have enough information to make a diagnosis, but further examination may be warranted.

Examination: face to face

For face-to-face examinations, ensure you wear appropriate PPE.

The examination will be guided by the history. This needs to be focused and the following list acts as a guide.

Does the patient appear unwell?

Inspection:

Is there any swelling or redness?
Check the pupil. Does it appear regular? Are both pupils equal and reacting to light and accommodation?
Is the sclera injected?
Are there any obvious external abnormalities, such as cystic lesions? You may need to evert the tarsal plate.
Check the eyelashes.

Palpation:

Palpate the adjacent sinuses. Is there any tenderness?
Palpate the temporal artery looking for tenderness with or without loss of pulsation, if felt relevant from the history.
Check eye movements. Is there any pain associated with movements, with or without diplopia?
Check cranial nerves 3, 4 and 6
Check visual acuity using a Snellen chart.

Investigations

Primary care investigations to consider include:

Blood work, including ESR and CRP
Fluorescein staining, if you have this in the surgery
Eye swab, if there is evidence of discharge
CT or MRI of the head depending on level of concern and local referral protocols

When to refer

Urgent same day ophthalmological review may be necessary depending on history and examination findings.

If you suspect temporal arteritis, urgent discussion with vascular surgeons, rheumatology or ophthalmology may be necessary, depending on your local referral pathways.

Urgent maxillo-facial review is needed if periorbital cellulitis is suspected. Urgent admission for CT/MRI of the head may be required if you suspect an intracranial bleed.

Consider urgent neurological referral if other intracranial pathology is suspected, such as a space-occupying lesion.

Consider ENT referral if a sinus pathology is suspected or a failure to respond to conventional treatment in primary care.

Causes

Ophthalmological causes: lid or eyelash problems

Styes
Meibomian cysts
Skin malignancy, such as squamous cell carcinoma or basal cell carcinoma
Blepharitis
Trichiasis

Ophthalmological causes: anterior chamber pathology

Acute infective conjunctivitis (viral or bacterial)
Corneal ulcers (including dendritic ulcers)
Keratitis
Iritis
Scleritis
Acute glaucoma
Foreign body
Corneal abrasion

Other causes

Migraine
Cluster headaches
Acute sinusitis
Temporal arteritis
Metastatic disease, such as cerebral metastases
Periorbital cellulitis
Ophthalmic shingles

Key learning points

A focused history and examination will often reveal the aetiology.
Consider investigations such as CRP and ESR.
Red flags include fever, recent trauma, vomiting, history of malignancy and if the patient is a contact lens wearer.
Consider urgent neurological referral if other intracranial pathology is suspected, such as a space-occupying lesion.
If you suspect temporal arteritis, urgent discussion with vascular surgeons, rheumatology or ophthalmology may be necessary.
Causes may be ophthalmological or may include migraine, sinusitis or shingles, for example.

Dr Pipin Singh is a GP in Northumberland