Determining the Cause

Chief Complaint: Eye Pain

A. History: Located in the Surface of the Eye (Cornea or Conjunctiva)

B. Further History: Redness, burning, foreign body sensation, stinging, or scratchy sensation, Blurry vision that improves with blinking, eye fatigue, Sensitivity to light (photophobia)

Pivotal Assessment	Finding

Eye fatigue (also called eye strain or asthenopia) is a common condition that happens when your eyes get tired from intense use, often after focusing on a task for a long time—like staring at screens, reading, or driving.

🔍 Common Symptoms of Eye Fatigue:

Tired, sore, or burning eyes
Dry or watery eyes
Blurred or double vision
Headache (especially around the eyes or temples)
Difficulty focusing
Increased sensitivity to light
Feeling like you need to close your eyes or rub them
Neck, shoulder, or back pain (due to poor posture while using screens)

🎯 Common Causes:

Prolonged screen use (computers, phones, tablets)
Poor lighting (too bright or too dim)
Reading or driving for long periods
Uncorrected vision problems (like needing glasses or an outdated prescription)
Glare from screens or windows
Not blinking enough (especially when using screens)

🛠️ Tips to Prevent and Relieve Eye Fatigue:

Follow the 20-20-20 Rule
Every 20 minutes, look at something 20 feet away for 20 seconds.
Use artificial tears
To keep your eyes moist.
Adjust your screen
Keep it at arm’s length and just below eye level.
Control lighting and glare
Use screen filters and adjust ambient lighting.
Get regular eye exams
To make sure your prescription is up to date.

Let me know if you’re experiencing any of these symptoms—happy to help you figure out if it’s just eye fatigue or something else going on.

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Watery eyes (paradoxical reflex tearing)

Differential Diagnosis

Dry eyes, conjunctivitis (pink eye), corneal abrasions, or foreign bodies (like dust or an eyelash).

Pivotal Assessment	Finding
History

The diagnosis of dry eye disease (DED), also known as keratoconjunctivitis sicca, is based on patient symptoms, clinical examination, and a few objective diagnostic tests. Here’s a structured approach:

🔍 1. History and Symptoms

Start by assessing the patient's symptoms:

Burning, stinging, or scratchy sensation
Foreign body sensation
Grittiness
Redness
Blurry vision that improves with blinking
Eye fatigue
Sensitivity to light (photophobia)
Watery eyes (paradoxical reflex tearing)

📄 Common tools:

Ocular Surface Disease Index (OSDI) questionnaire
DEQ-5 (Dry Eye Questionnaire)

👁️ 2. Physical Exam

Look for:

Redness of the conjunctiva
Decreased tear meniscus
Eyelid or meibomian gland dysfunction (MGD)
Blinking pattern (infrequent/incomplete blinking)

🧪 3. Diagnostic Tests

These help confirm the diagnosis and subtype (aqueous-deficient vs evaporative):

a) Tear Break-Up Time (TBUT)

Instill fluorescein dye.
Ask the patient not to blink.
Measure time until the first dry spot appears.
TBUT < 10 seconds suggests instability of the tear film.

b) Schirmer’s Test

Place filter paper strip in the lower eyelid.
Measure wetting after 5 minutes.
<10 mm wetting is suggestive of aqueous-deficient dry eye.
- With anesthesia → reflects basal secretion
- Without → includes reflex tearing

c) Ocular Surface Staining

Use fluorescein (cornea), lissamine green or rose bengal (conjunctiva).
Positive staining indicates surface damage.

d) Tear Osmolarity

Measured with devices like TearLab.
>308 mOsm/L or >8 mOsm/L difference between eyes suggests dry eye.

e) Meibography

Imaging of the meibomian glands to assess for dropout or dysfunction (evaporative DED).

🧠 4. Consider Underlying Causes or Risk Factors

Autoimmune diseases (e.g., Sjögren's syndrome)
Medications (e.g., antihistamines, antidepressants, isotretinoin)
Contact lens use
Screen exposure and low blink rate
Hormonal changes (especially postmenopausal women)

🧬 5. Lab Tests (If Indicated)

Autoantibodies (e.g., ANA, anti-Ro/SSA, anti-La/SSB) if Sjögren’s syndrome is suspected
Rheumatology referral for systemic autoimmune workup

Here’s a quick diagnostic flowchart for Dry Eye Disease (DED):

🌿 Dry Eye Disease Diagnostic Flowchart

        ┌────────────────────────────┐          │  Step 1: Symptom Screening │          └────────────────────────────┘                    ↓      ┌─────────────────────────────────────────┐      │ Use OSDI or DEQ-5 questionnaires        │      │ OR ask about dryness, grittiness, etc.  │      └─────────────────────────────────────────┘                    ↓          ┌─────────────────────────────┐          │  Step 2: Clinical Exam      │          └─────────────────────────────┘                    ↓      ┌─────────────────────────────────────────┐      │ Look for signs:                         │      │ - Conjunctival injection                │      │ - Reduced tear meniscus                 │      │ - Lid margin or meibomian gland issues │      └─────────────────────────────────────────┘                    ↓          ┌─────────────────────────────┐          │  Step 3: Diagnostic Tests   │          └─────────────────────────────┘                    ↓      ┌─────────────────────────────────────────────┐      │ - TBUT < 10 sec → Tear instability          │      │ - Schirmer’s test < 10 mm → Low tear volume │      │ - Fluorescein/lissamine green staining      │      │ - Tear osmolarity > 308 mOsm/L              │      └─────────────────────────────────────────────┘                    ↓          ┌─────────────────────────────┐          │  Step 4: Subtype & Severity│          └─────────────────────────────┘                    ↓      ┌──────────────────────────────────────────────┐      │ - Aqueous-deficient (↓ Schirmer)             │      │ - Evaporative (MGD, ↑ TBUT, normal Schirmer) │      └──────────────────────────────────────────────┘                    ↓          ┌─────────────────────────────┐          │  Step 5: Consider Labs      │          └─────────────────────────────┘                    ↓      ┌──────────────────────────────────────────────┐      │ If autoimmune signs: ANA, SSA, SSB, etc.     │      │ Consider referral for Sjögren’s workup       │      └──────────────────────────────────────────────┘

2. Deep within the Eye

Symptoms: A dull ache or pressure sensation.

Possible Causes: Conditions like uveitis (inflammation of the uvea), glaucoma, or retinal issues.

3. Around the Eyes (Orbit or Eyelids)

Symptoms: Pain or swelling around the eyes, possibly accompanied by redness or discharge.

Possible Causes: Sinusitis, orbital cellulitis (infection of the tissues around the eye), or blepharitis (inflammation of the eyelids).

4. One Eye vs. Both Eyes

One Eye: Conditions like a foreign body, corneal abrasion, or infection (like conjunctivitis) often affect one eye.

Both Eyes: Bilateral symptoms might suggest dry eyes, allergies, or systemic conditions like migraines.

5. Specific Areas

Inner Corner of the Eye: Could be related to tear duct issues or dacryocystitis (inflammation of the tear sac).

Outer Corner of the Eye: Might be associated with conditions like blepharitis or a stye (hordeolum).

Behind the Eye: Could indicate issues like sinusitis, migraines, or referred pain from the neck or head.

By pinpointing the exact location of the pain, you can narrow down the potential causes and provide valuable information to healthcare professionals, helping them make a more accurate diagnosis.

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Chief Complaint:: Eye Pain

A. History: Located in both eyes

Location: Is the pain in one eye or both? Is it localized to the surface of the eye, or does it feel like it's deeper?

Pivotal Assessment	Finding
History

Determining the cause of eye pain can be a bit of a puzzle, but let's break it down step by step. Here's a comprehensive guide to help you figure out what might be going on:

1. Location and Type of Pain

Location: Is the pain in one eye or both? Is it localized to the surface of the eye, or does it feel like it's deeper?

Type of Pain: Is it a sharp, stabbing pain, a dull ache, burning, itching, or feeling of pressure?

2. Common Causes

Dry Eyes: Often feels like grittiness or burning, especially if you're exposed to screens for long periods or live in a dry climate.

Allergies: Itching, redness, and watery eyes can be due to seasonal allergies or exposure to allergens like pet dander.

Foreign Body: A sensation of something being in your eye could be due to dust, an eyelash, or a contact lens issue.

Infections or Inflammations: Conjunctivitis (pink eye), blepharitis (inflammation of the eyelids), or uveitis (inflammation of the uvea) can cause pain, redness, and discharge.

Vision Problems: Uncorrected vision problems or needing a change in your prescription can cause eye strain and pain.

Headaches: Migraines or tension headaches can sometimes cause or contribute to eye pain.

Sinus Pressure: Sinus infections or allergies can cause referred pain around the eyes.

3. Additional Symptoms

Vision Changes: Blurred vision, double vision, or seeing halos around lights.

Discharge or Redness: Yellow or green discharge, or noticeable redness in the eye(s).

Sensitivity to Light: Increased sensitivity to light or glare.

Headache or Facial Pain: Pain that radiates to the forehead, temples, or cheeks.

4. When to Seek Medical Attention

Sudden onset of severe eye pain.

Eye trauma or injury.

Vision changes or loss.

Increased sensitivity to light.

Presence of discharge or redness.

Fever or systemic symptoms like nausea or vomiting.

5. Diagnostic Steps

Self-Assessment: Reflect on your symptoms, recent activities, and any changes in your environment or health.

Eye Care Professional: Schedule an appointment with an optometrist or ophthalmologist for a comprehensive eye exam. They can perform tests to assess your vision, eye health, and possibly prescribe medication if needed.

6. Preventive Measures

Regular Eye Exams: Keep up with regular check-ups to monitor your eye health.

Protective Eyewear: Use sunglasses with UV protection and safety glasses when engaging in activities that could potentially harm your eyes.

Screen Time: Follow the 20-20-20 rule (every 20 minutes, look at something 20 feet away for 20 seconds) to reduce eye strain.

7. Home Remedies

Warm Compresses: Can help with dry eyes or eyelid inflammation.

Artificial Tears: Over-the-counter drops can provide relief for dry eyes.

Rest: Give your eyes a break from screens and activities that strain them.

By considering these factors and possibly consulting with a healthcare professional, you can better understand the cause of your eye pain and find appropriate relief.