The patient is a 44-year-old male with a past history of end stage renal disease on hemodialysis, diabetes, and hypertension who presents with acute visual loss after assault 2 hours prior. He was struck in the eye by his partner’s fist (adorned with a large ring), but denies severe pain. He does endorses instant difficulty with his vision. There is no use of contacts or glasses. No other injuries, headache, or loss of consciousness are reported.
Chief complaint: Double vision
History of Present Illness: 61 year old female with history of HTN, DM, hyperlipidemia, and chronic low back pain presenting with double vision. She received an epidural spinal injection yesterday for the 4th time for low back pain. She was sedated for the procedure and woke up with headache, neck stiffness, and left eye “jumping around,” which progressed to double vision 1 hour later.
There was no blurry or double vision with either eye closed. She had 1 episode of emesis. She presented to the ED 24 hours later with continued headache and double vision.
Chief complaint: Left eye pain, redness, and foreign body sensation
History of Present Illness: 39 year old man presents after metal grinding without protective eyewear three days prior.
He had felt something strike his left eye. He developed “burning” pain, tearing, and redness. Pain worsens with extraocular movements. He notes that vision in his right eye has always been worse than the left. Denies any other visual complaints.
Chief complaint: Headaches for 1 year
History of Present Illness: A 31-year-old woman with no significant past history presents with a dull headache.
She notes the headache is generalized, has been almost daily for a year and is worsened by bending over. She denies nausea, vomiting, photophobia, trauma, seizures, focal weakness, numbness, or vision change. Acetaminophen and ibuprofen provide only mild, short-acting relief. She takes oral birth control and her periods have been normal.
Chief complaint: Eye pain
History of Present Illness: A 41-year-old man presents with pain and a foreign body sensation in the right eye since welding 4 days ago. The patient wore eye protective gear; however, he explains that he only wore sunglasses. A spark flew in from above his glasses and hit him in the right eye. The pain has been steady since. He complains of irritation exacerbated by blinking, but vision has remained unchanged. He has no other injury and no other physical complaint.
There is significant overlap among conditions that cause a red, painful, or red AND painful eye. Having trouble keeping them all straight? Need a refresher before heading in to see a patient with a new eye complaint? Check out our brief, practical ALiEM Cards on the topic:
- The Painful Eye (Author: Puja Gopal, MD)
- The Red Eye (Author: Michelle Lin, MD)
- Eye Differential Diagnoses (Author: Puja Gopal, MD)
Our latest ALiEM Card introduces the “Rule of 2’s,” a simple method that uses eye anatomy to help you recall some of the major ocular diagnoses! It builds a framework for your physical exam and will help you include or eliminate some of the more common ocular conditions.
The Rule of 2’s is easy to remember: 2 eyes, 2 major diagnoses to consider for each ocular layer, as you move anterior to posterior.