Applying the mnemonic MINT to the various anatomic parts of the eye will aid in systematically developing a list of diagnostic possibilities for eye pain.
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Eye pain |
· M—Malformations most certainly suggest glaucoma and all the refractive disorders (e.g., astigmatism, myopia, hypermetropia).
· I—Inflammation accounts for most cases. One anatomically recalls conjuctivitis, keratitis, scleritis, corneal ulcers, iridocyclitis, and optic neuritis. Do not forget inflammation of the orbit. Vasculitis from temporal arteritis must be considered with obstruction of the retinal veins or arteries.
· N—Neoplasms are unlikely causes but must be considered.
· T—Trauma should suggest abrasions and foreign bodies, particularly those of the cornea.
Eye pain, like earache, may be referred. Cerebral neoplasms, migraine, and sinusitis may all present with orbital or retroorbital pain. An additional category of etiologies that is not common in earache is systemic disease. Any febrile disease may cause bilateral eye pain, particularly viral influenza.
Approach to the Diagnosis
The approach to the diagnosis of eye pain involves a careful search for inflammation of the various anatomic structures; then a drop or two of fluorescent dye is inserted and the cornea inspected for lacerations, herpes ulcers, and foreign bodies. Finally, tonometry may be done. Referral to an ophthalmologist is often necessary, but the astute clinician will want to x-ray the sinuses, ask about a history of migraine, do a visual field, and rule out systemic diseases beforehand.
Other Useful Tests
1. Smear and culture of exudate (conjunctivitis)
2. Smear for eosinophils (allergic conjunctivitis)
3. Histamine test (cluster headaches)
4. Sedimentation rate (temporal arteritis)
5. X-ray of sinuses (sinusitis)
6. Visual fields (glaucoma)
7. Slit lamp examination (iriditis)
8. CT scan of brain (tumors, abscess)
9. Temporal artery biopsy (temporal arteritis)
Case Presentation #24
A 56-year-old white woman complained of headache and pain in the right eye for 3 days associated with nausea and vomiting.
Question #1. Applying the methods presented above, what is your list of possibilities?
Further questioning reveals that she has also noticed blurring of vision in the right eye associated with halos around objects. There is no history of previous attacks and her neurologic examination is normal.
Question #2. What diagnosis would you consider now?
