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

See 8.4, Esodeviations in Children (eyes turned in), or 8.5, Exodeviations in Children (eyes turned out).

DECREASED VISION

1. 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, giant cell arteritis, orbital lesion (vision loss may be associated with eye movement).

2. Visual loss lasting >24 hours

—Sudden, painless loss

More Common. Retinal artery or vein occlusion, ischemic optic neuropathy, vitreous hemorrhage, retinal detachment, optic neuritis (pain with eye movement in >50% of cases), sudden discovery of preexisting unilateral visual loss.

Less Common. Other retinal or CNS disease (e.g., stroke), 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).

3. Posttraumatic visual loss: Eyelid swelling, corneal irregularity, hyphema, ruptured globe, traumatic cataract, lens dislocation, commotio retinae, retinal detachment, retinal or vitreous hemorrhage, traumatic optic neuropathy, cranial neuropathies, CNS injury.

NOTE: Always remember nonphysiologic visual loss.

DISCHARGE

See “Red Eye” in this chapter.

DISTORTION OF VISION

More Common. Refractive error [including presbyopia, acquired myopia (e.g., from cataract, diabetes, ciliary spasm, medications, retinal detachment surgery), acquired astigmatism (e.g., from anterior segment surgery, chalazion, orbital fracture, and edema)], 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)

1. 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.

2. 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, undercor­rection or overcorrection after 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); internuclear ophthalmoplegia; vertebrobasilar artery insufficiency; other CNS lesions; spectacle problem.

DRY EYES

See 4.3, Dry-Eye Syndrome.

EYELASH LOSS

Trauma, burn, thyroid disease, Vogt–Koyanagi– Harada syndrome, eyelid infection or inflammation, radiation, chronic skin disease (e.g., alopecia areata), cutaneous neoplasm, trichotillomania.

EYELID CRUSTING

More Common. Blepharitis, meibomitis, conjunctivitis.

Less Common. Canaliculitis, nasolacrimal duct obstruction, dacryocystitis.

EYELIDS DROOPING (PTOSIS)

See 6.1, Ptosis.

EYELID SWELLING

1. Associated with inflammation (usually erythematous).

More Common. Hordeolum, blepharitis, conjunctivitis, preseptal or orbital cellulitis, trauma, contact dermatitis, herpes simplex or zoster dermatitis.

Less Common. Ectropion, corneal abnormality, urticaria or angioedema, blepharochalasis, insect bite, dacryoadenitis, erysipelas, eyelid or lacrimal gland mass, autoimmunities (e.g., discoid lupus, dermatomyositis).

2. Noninflammatory: Chalazion; dermatochalasis; prolapse of orbital fat (retropulsion of the globe increases the prolapse); laxity of the eyelid skin; cardiac, renal, or thyroid disease; superior vena cava syndrome; eyelid or lacrimal gland mass, foreign body.

EYELID TWITCH

Orbicularis myokymia (related to fatigue, excess caffeine, medication, or stress), corneal or conjunctival irritation (especially from an eyelash, cyst, or conjunctival foreign body), dry eye, blepharospasm (bilateral), hemifacial spasm, albinism (photosensitivity), serum electrolyte abnormality, tourettes, tic douloureux, anemia (rarely).

EYELIDS UNABLE TO CLOSE (LAGOPHTHALMOS)

Severe proptosis, severe chemosis, eyelid scarring, eyelid retractor muscle scarring, seventh cranial nerve palsy, status-post facial cosmetic or reconstructive surgery.

EYES “BULGING” (PROPTOSIS)

See 7.1, Orbital Disease.

EYES “JUMPING” (OSCILLOPSIA)

Acquired nystagmus, internuclear ophthalmoplegia, myasthenia gravis, vestibular function loss, opsoclonus/ocular flutter, superior oblique myokymia, various CNS disorders.

FLASHES OF LIGHT

More Common. Retinal break or detachment, posterior vitreous detachment, migraine, rapid eye movements (particularly in darkness), oculodigital stimulation.

Less Common. CNS (particularly occipital lobe) disorders, vestibulobasilar artery insufficiency, optic neuropathies, retinitis, entoptic phenomena, hallucinations.

FLOATERS

See “Spots in Front of the Eyes” in this chapter.

FOREIGN BODY SENSATION

Dry-eye syndrome, blepharitis, conjunctivitis, trichiasis, corneal abnormality (e.g., corneal abrasion or foreign body, recurrent erosion, superficial punctate keratopathy), contact lens-related problem, episcleritis, pterygium, pinguecula.

GLARE

Cataract, pseudophakia, posterior capsular opacity, corneal irregularity or opacity, altered pupillary structure or response, status-post refractive surgery, posterior vitreous detachment, pharmacologic (e.g., atropine).

HALLUCINATIONS (FORMED IMAGES)

Posterior vitreous detachments (white lightning streaks of Moore), retinal detachment, optic neuropathies, blind eyes, bilateral eye patching, Charles Bonnet syndrome, psychosis, parietotemporal area lesions, other CNS causes, medications.

HALOS AROUND LIGHTS

Cataract, pseudophakia, posterior capsular opacity, acute angle-closure glaucoma or corneal edema from another cause (e.g., aphakic or pseudophakic bullous keratopathy, contact lens overwear), corneal dystrophies, status-post refractive surgery, corneal haziness, discharge, pigment dispersion syndrome, vitreous opacities, drugs (e.g., digitalis, chloroquine).

HEADACHE

See 10.26, Headache.

ITCHY EYES

Conjunctivitis (especially allergic, vernal, and viral), blepharitis, dry-eye syndrome, topical drug allergy or contact dermatitis, giant papillary conjunctivitis, or another contact lens-related problem.

LIGHT SENSITIVITY (PHOTOPHOBIA)

1. Abnormal eye examination

More Common. Corneal abnormality (e.g., abrasion or edema), anterior uveitis.

Less Common. Conjunctivitis (mild photophobia), posterior uveitis, scleritis, albinism, total color blindness, aniridia, mydriasis of any etiology (e.g., pharmacologic, traumatic), congenital glaucoma.

2. Normal eye examination: Migraine, meningitis, retrobulbar optic neuritis, subarachnoid hemorrhage, trigeminal neuralgia, or a lightly pigmented eye.

NIGHT BLINDNESS

More Common. Refractive error (especially undercorrected myopia), advanced glaucoma or optic atrophy, small pupil (especially from miotic drops), retinitis pigmentosa, congenital stationary night blindness, status-post panretinal photocoagulation drugs (e.g., phenothiazines, chloroquine, quinine).

Less Common. Vitamin A deficiency, gyrate atrophy, choroideremia.

PAIN

1. Ocular

—Typically mild to moderate: Dry-eye syndrome, blepharitis, infectious conjunctivitis, episcleritis, inflamed pinguecula or pterygium, foreign body (corneal or conjunctival), corneal disorder (e.g., superficial punctate keratopathy), superior limbic keratoconjunctivitis, ocular medication toxicity, contact lens-related problems, postoperative, ocular ischemic syndrome, eye strain from uncorrected refractive error.

—Typically moderate to severe: Corneal disorder (e.g., abrasion, erosion, infiltrate/ulcer/keratitis, chemical injury, ultraviolet burn), trauma, anterior uveitis, scleritis, endophthalmitis, acute angle-closure glaucoma.

2. Periorbital: Trauma, hordeolum, preseptal cellulitis, dacryocystitis, dermatitis (e.g., contact, chemical, varicella zoster, or herpes simplex), referred pain (e.g., dental, sinus), tic douloureux.

3. Orbital: Sinusitis, trauma, orbital cellulitis, idiopathic orbital inflammatory syndrome orbital tumor or mass, optic neuritis, acute dacryoadenitis, migraine or cluster headache, diabetic cranial nerve palsy.

4. Asthenopia: Uncorrected refractive error, phoria or tropia, convergence insufficiency, accommodative spasm, pharmacologic (miotics).

RED EYE

1. Adnexal causes: Trichiasis, distichiasis, floppy eyelid syndrome, entropion or ectropion, lagophthalmos (incomplete eyelid closure), blepharitis, meibomitis, acne rosacea, dacryocystitis, canaliculitis.

2. Conjunctival causes: Ophthalmia neonatorum in infants, conjunctivitis (bacterial, viral, chemical, allergic, atopic, vernal, medication toxicity), subconjunctival hemorrhage, inflamed pinguecula, superior limbic keratoconjunctivitis, giant papillary conjunctivitis, conjunctival foreign body, symblepharon and associated etiologies (e.g., ocular cicatricial pemphigoid, Stevens– Johnson syndrome, toxic epidermal necrolysis), conjunctival neoplasia.

3. Corneal causes: Infectious or inflammatory keratitis, contact lens-related problems (see 4.21, Contact Lens-Related Problems), corneal foreign body, recurrent corneal erosion, pterygium, neurotrophic keratopathy, medicamentosa, ultraviolet or chemical burn.

4. Other: Trauma, postoperative, dry-eye syndrome, endophthalmitis, anterior uveitis, episcleritis, scleritis, pharmacologic (e.g., prostaglandin analogs), angle-closure glaucoma, carotid–cavernous fistula (corkscrew conjunctival vessels), cluster headache.

“SPOTS” IN FRONT OF THE EYES

1. Transient: Migraine.

2. Permanent or long-standing

More Common. Posterior vitreous detachment, intermediate or posterior uveitis, vitreous hemorrhage, vitreous condensations/debris.

Less Common. Microhyphema, hyphema, retinal break or detachment, corneal opacity or foreign body.

NOTE: Some patients are referring to a blind spot in their visual field caused by a retinal, optic nerve, or CNS disorder.

TEARING

1. Adults

—Pain present: Corneal abnormality (e.g., abrasion, foreign body or rust ring, recurrent erosion, edema), anterior uveitis, eyelash or eyelid disorder (e.g., trichiasis, entropion), conjunctival foreign body, dacryocystitis, dacryoadenitis, canaliculitis, trauma.

—Minimal/no pain: Dry-eye syndrome, blepharitis, nasolacrimal duct obstruction, punctal occlusion, lacrimal sac mass, ectropion, conjunctivitis (especially allergic and toxic), emotional states, crocodile tears (congenital or seventh nerve palsy).

2. Children: Nasolacrimal duct obstruction, congenital glaucoma, corneal or conjunctival foreign body, or other irritative disorder.

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