Differential Diagnosis of Ocular Symptoms
Burning
More Common. Blepharitis, meibomitis, dry eye syndrome, conjunctivitis (infectious, allergic, mechanical, chemical).
Less Common. Corneal defects (usually marked by fluorescein staining of the cornea), inflamed pterygium or pinguecula, episcleritis, superior limbic keratoconjunctivitis, ocular toxicity (medication, makeup, contact lens solutions), contact lens-related problems.
Crossed Eyes in Children
Decreased Vision
Transient visual loss (vision returns to normal within 24 hours, usually within 1 hour).
More Common. Few seconds (usually bilateral): Papilledema. Few minutes: Amaurosis fugax (transient ischemic attack; unilateral), vertebrobasilar artery insufficiency (bilateral). Ten to 60 minutes: Migraine (with or without a subsequent headache).
Less Common. Impending central retinal vein occlusion, ischemic optic neuropathy, ocular ischemic syndrome (carotid occlusive disease), glaucoma, sudden change in blood pressure, central nervous system (CNS) lesion, optic disc drusen, orbital lesion (vision loss may be associated with eye movement).
Visual loss lasting >24 hours
Sudden, painless loss
More Common. Retinal artery or vein occlusion, ischemic optic neuropathy, giant cell arteritis, vitreous hemorrhage, retinal detachment, optic neuritis (pain with eye movement in >50% of cases), sudden discovery of pre-existing unilateral visual loss.
Less Common. Other retinal or CNS disease (e.g., stroke), toxins (e.g., methanol poisoning), ophthalmic artery occlusion (may also have extraocular motility deficits and ptosis).
Gradual, painless loss (over weeks, months, or years)
More Common. Cataract, refractive error, open angle glaucoma, chronic angle closure glaucoma, chronic retinal disease [e.g., age-related macular degeneration (ARMD), diabetic retinopathy].
Less Common. Chronic corneal disease (e.g., corneal dystrophy), optic neuropathy/atrophy (e.g., CNS tumor).
Painful loss: Acute angle closure glaucoma, optic neuritis (may have pain with eye movements), uveitis, endophthalmitis, corneal hydrops (keratoconus).
Posttraumatic visual loss: Eyelid swelling, corneal irregularity, hyphema, ruptured globe, traumatic cataract, commotio retinae, retinal detachment, retinal or vitreous hemorrhage, lens dislocation, traumatic optic neuropathy, cranial neuropathies, CNS injury, sympathetic ophthalmia (rare).
NOTE: Although a diagnosis of exclusion, remember to consider nonphysiologic vision loss.Distortion of Vision
More Common. Refractive error [including presbyopia, acquired myopia (e.g., from cataract, diabetes, pregnancy, ciliary spasm or ciliary body rotation, medications, retinal detachment surgery), acquired astigmatism (e.g., from anterior segment surgery, periorbital or eyelid edema/mass [e.g., chalazion, orbital trauma]), macular disease (e.g., central serous chorioretinopathy, macular edema, ARMD, and others associated with choroidal neovascular membranes [CNVMs]), corneal irregularity, intoxication (e.g., ethanol, methanol), pharmacologic (e.g., scopolamine patch).
Less Common. Keratoconus, topical eye drops (e.g., miotics, cycloplegics), retinal detachment, migraine (transient), hypotony, CNS abnormality (including papilledema), nonphysiologic.
Double Vision (Diplopia)
Monocular (diplopia remains when the uninvolved eye is occluded)
More Common. Refractive error, incorrect spectacle alignment, corneal opacity or irregularity (including corneal or refractive surgery), cataract, iris defects (e.g., iridectomy).
Less Common. Dislocated natural lens or lens implant, macular disease, retinal detachment, CNS causes (rare), nonphysiologic.
Binocular (diplopia eliminated when either eye is occluded)
Typically intermittent: Myasthenia gravis, intermittent decompensation of an existing phoria.
Constant: Isolated sixth, third, or fourth nerve palsy; orbital disease (e.g., thyroid eye disease; idiopathic orbital inflammation [orbital pseudotumor], tumor); cavernous sinus/superior orbital fissure syndrome; status-post ocular surgery (e.g., residual anesthesia, displaced muscle, muscle surgery, restriction from scleral buckle, severe aniseikonia after refractive surgery); status-post trauma (e.g., orbital wall fracture with extraocular muscle entrapment, orbital edema); convergence/divergence insufficiency; internuclear ophthalmoplegia; vertebrobasilar artery insufficiency; other CNS lesions; spectacle problem.
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