Tenderness and aching in the right eye after a period of stress

The question:

A patient in their 30s presents in practice, complaining of redness, aching and tenderness in their right eye. They report that their vision is unaffected, but that they have been signed off work with stress and have been fatigued in recent weeks. What is your diagnosis?

OT’s panel says...

Ankur Trivedi (AT): I would want to start by asking how long it has been an issue. Did it start with one eye and then spread to the other? If so, I would like a timeframe for this, and for the patient to rate the pain or ache on a scale of 0–10. Whilst talking to them, I would look at the redness – does it appear general or localised? Is the redness of the eye itself, or more on the lids, or both? Is there any discharge, and if so is it watery or gunky?

My first thoughts of possible diagnosis (not exhaustive) would be conjunctivitis, uveitis, episcleritis, sub conjunctival haemorrhage, keratitis, or acute angle closure. The above questioning would make certain things move up the list of likelihood to then be supported or confirmed by further questioning and examination.

I would also enquire about general health, medications, known allergies, and any previous ocular history. If they have been off work with stress, have they also been physically unwell? I would ask about any contact lens use or recent ocular trauma. Is there any family history? Has anyone had something similar at home or work?

On more specific examination – slit lamp and fluorescein – I would be looking for any more detailed signs of the issues or the cause, including everting the lid to reassure myself that there is no palpebral foreign body present, and seeing if there are any localised changes, for example follicles or papillae. I would also want to check that the intraocular pressures (IOP) are within normal range.

I would ask about other systemic inflammatory conditions, especially rheumatoid arthritis and inflammatory bowel disease

Ceri Smith Jaynes: Uniocular ache, redness, tenderness, but not particularly painful or photophobic – she’s a bit young for angle closure, and this sounds a bit tame for iritis or a corneal ulcer. From Ankur’s list of differential diagnoses, I’m going to plump for episcleritis.

I would ask about other systemic inflammatory conditions, especially rheumatoid arthritis and inflammatory bowel disease. I would have a good look at the sclera and check the anterior chamber carefully for cells. The redness can be sectoral and sometimes there will be a whitish nodule in the centre of the red bit. We don’t have phenylephrine in the cupboard in my practice, but I hear you can use it to aid diagnosis eg for episcleral vessels blanch, but scleritis would remain red and angry.

Patients are normally quite reassured to hear it is self-limiting and could improve without treatment within a few weeks. Cool compresses and lubricants can ease the symptoms, but a ‘soft’ non-penetrating steroid would help it along.

As long as she is not pregnant or breastfeeding, I could offer the patient fluoromethalone (FML) four times a day – it’s on our local formulary, and usually easy to obtain in the pharmacies. I’d need a baseline IOP, and I’d recheck her in a couple of weeks with the usual ‘ring me if it doesn’t start to improve in a few days or symptoms worsen’ guidance. I’d be seeing her under the local Community Urgent Eyecare Service, so the doctor would be notified. However, if it recurs, I would write to the doctor. Would you prescribe a steroid, Kevin and Ankur? If so, which one?

Kevin Wallace: My protocol is very close to what Ceri said – as usual, the key is to rule out anything more significant.

My advice always finishes with something along the lines of: ‘this is all based on the presentation today. I expect this to get better over the next week or so – but if you get more redness, more pain, photophobia or worsening vision, I want to see you again because that would indicate something more serious.’

I keep phenylephrine and find it useful in these cases. It is reassuring to the patient when their eye goes nearly back to normal that there isn’t something more significant going on – but they’re always disappointed when I tell them it will wear off shortly.

I would usually just, as Ceri said, give a lubricant, cool compress, and systemic NSAID if appropriate. I reserve steroids for more severe or long-lasting cases. I don’t do it very often for episcleritis, but if I do my first choice is FML – it’s effective and doesn’t have the same risks as more potent (or penetrating) options. I’ve never seen it affect the IOP, but I always measure it before starting and after a period of treatment just to make sure.

It can be a frustrating condition for patients because they want immediate relief – and that is not usually the case – but often they are reassured when told that it’s just inflammation and not infection or anything more significant.

AT: Yes, I have also used FML in cases where the low-level treatment, as already mentioned, has not resolved the episode. Also, I would make sure the patient’s GP is looped in if there is a reoccurrence, so any possible systemic issues could be considered.

For advice in any situation where you are unsure how to manage a patient, contact the AOP’s clinical and regulatory team via email or phone on 0207 549 2020, extension 1.