Eye pain

ACUTE PAIN VERY:

Glaucoma attack acute angle closure:

Signs of acute glaucoma attack angle closure are:

– Unilateral eye pain with decreased visual acuity;

– Cloudy cornea;

– Semi pupil mydriasis;

– Redness often limited to a circle périkératique;

– Very hard look at palpation.

The treatment is urgent hospital eye clinic. It is preferable if possible to administer at diagnosis Diamox® an intravenous injection of (carbonic anhydrase inhibitor) or at least give Diamox® orally.

_ Crisis subacute glaucoma angle closure

One has to know the sub-acute attacks of glaucoma angle closure.

These are crises of temporary unilateral eye pain. The same side is always concerned. Indeed if both eyes are generally predisposed, they often are asymmetrically.

The immediate causes are numerous and include all situations in which the pupil is capable of expanding: first drugs ocular general or local route or neighborhood (see Box 1), but also physiological dilation in the dark over some sleep.

Search existence in the subacute crises of perception of fog, a halo around lights (like halos observable winter around outdoor lights when the weather is wet).

During the episode, the eye is hard and some patients, especially young people (the classic profile of the elderly woman farsighted is not exclusive), spontaneously talk about a hard look and consult for this reason.

A consultation with an ophthalmologist is necessary, especially as the functional signs are usually very discreet. The practice of a peripheral laser iridotomy is imperative and permanently prevents the occurrence of an acute glaucoma attack in angle closure.

Box 1. Drugs, misleading instructions
Numerous drugs are “against-indicated in cases of glaucoma”: antidepressants, anxiolytics, anti-Parkinson, relaxants, amphetamines, cough suppressants, medication for benign prostatic hyperplasia, etc.
These medications “against-indicated in cases of glaucoma” are potentially pupil dilating medicines. These constitute a risk for narrow anterior chamber patients in whom the anterior chamber angle is likely to close in such dilated iris situation and lead to acute glaucoma attack.
However, these patients are not glaucoma, do not feel concerned by this reference, while chronic glaucoma open angle without risk of acute angle closure are alarmed unnecessarily or refrain from taking the drugs.
Once the diagnosis of narrow anterior chamber at risk established by the ophthalmologist, usually during a routine examination, a YAG laser iridotomy is indicated. This achieved, all these drugs become again
authorized again.

Uveitis:

Uveitis can become very painful, especially after a few days of evolution without treatment. This is in Behçet’s disease, Syndrome Fiessinger Reiter, uveitis ankylosing spondyloarthritis (SPA), rheumatoid arthritis, idiopathic uveitis, etc.(See Red Eye).

Endophthalmitis:

It is important to recognize infectious uveitis, commonly referred to as endophthalmitis or panophthalmitis in its most severe acute, postoperative. In the days following an “ordinary” procedure (cataract, for example), a major pain with visual loss, redness, discharge, appears suddenly. There is also, though more rarely, through blood endophthalmitis.

The urgency is extreme, requiring care in a specialized (intravitreal injection of antibiotics and intravenous antibiotics).Symptoms are most intense gravity and urgency even more important that pain occurs shortly after surgery the next day or two.

Keratitis:

Keratitis give a grain of sand sensation, photophobia, red eye with périkératique circle and often tearful. Besides infectious causes, often in the form of keratoconjunctivitis, bacterial or viral, add all that is apparent: corneal foreign body, foreign body under the upper eyelid, arc flash welding, projection tear gas and other irritants.

Projection of a product in the eye:

Before any projection of a product in the eye,

must immediately flush the eye with saline for at least 5 minutes, failing to running water. Note that the bases are generally more dangerous than acids because they can penetrate deep. The eye wash must eventually be extended over several hours.

Lentils:

At a carrier of contact lenses, especially soft lenses, any painful symptoms with red eye needs to fear a potentially serious complication.

Remove the lenses and consult an ophthalmologist immediately. For soft lenses, the fear is the amoebic keratitis in treated urgently.

If left amoebae invade the corneal stroma and encyst to, corneal and visual prognosis is very grim. However, urgent treatment by antiseptic salve based amidines helps eradicate the condition of one drop every hour for 48 hours.

At a more advanced stage of corneal abscesses, a white spot is visible on the cornea and grows more or less quickly.

This abscess requires an ophthalmological hospital environment management, notably with the application of so-called fortified eye drops, hospital pharmacy prepared from injectable antibiotics.

Must inform users of the risk of amoebic contamination of contact lenses by running water and stress the importance of strict hygiene (washed and dried hands to manipulate lenses, regular changes of cases and housings), dangers the contact of water with soft lenses, for example in the shower or pool, and the need to remove the lens and quickly check if red eye.

Foreign body:

Generally, if foreign body sensation brought by a gust of wind, apply the following rules:

– Do not rub hoping tearing the intruder hunting reflex;

– Rinse if necessary, preferably saline, to the extent possible by turning the lid or with the aid of a clean eye cup.

In case of persistent discomfort, ophthalmologic consultation is required urgently.

Metallic foreign body:

If foreign body projected on the eye at a professional handicraft or DIY, do not expect to see as corneal metallic foreign bodies oxidize rapidly. Rust broadcasts with hours and more deeply infiltrates the corneal stroma.

Ophthalmologic consultation is urgently needed to remove the slit lamp the foreign body and the ring of possible rust.Cicatrizing and antiseptic eye drops are instilled for a few days. Ensure that there is no penetration of intraocular foreign body. In addition, the intraocular penetration of a foreign body, still very serious, may go unnoticed.

Concretions:

Foreign body sensation sometimes a local cause which reports the existence of concretions “limestone” at the palpebral conjunctiva, eroding the conjunctival surface.

The ophthalmologist discovers turning the upper eyelid.

Removing concretions on the field at the slit lamp with a simple surface anesthesia instillation, the patient is relieved.

However, in place allowed concretions which the conjunctival surface coating is intact.

Conjunctivitis and keratoconjunctivitis:

The pain of conjunctivitis is also accompanied by a foreign body sensation, sand in the eye, with sticky secretions eyelashes.

The damage can be unilateral (viral keratoconjunctivitis is often unilateral at first) or bilateral, immediately or in a second time. The eye is red (see above, Chapter Red Eye).

Keratitis exposure:

exposure keratitis, such as when facial paralysis that leave the eye sufficiently covered by the eyelid, especially at night, can cause a foreign body sensation.

often it can be prevented by application to the eye of eye ointment, but tarsorrhaphy may be required in certain severe cases.

Neurotrophic keratitis:

Neurotrophic keratitis is secondary to the achievement of the ophthalmic branch of the trigeminal nerve (V1), responsible for corneal anesthesia and are particularly difficult to treat. This damage is often secondary to a neighborhood pathology (tumor, postoperative) but also an ophthalmic zoster.

Prevention: to recognize a herpetic origin when the eruption is very limited, especially in the nasal orifice, in a patient with an obvious deterioration of general condition, helps establish early antiviral treatment adapted (Zélitrex®) through General and avoid such complications.

Eyelid causes:

Spasmodic entropion:

Spasmodic entropion are the cause of sometimes violent pain by corneal irritation.

The patient’s lower eyelid is rolled inwardly intermittently causing the coming eyelashes rub on the cornea.

Most often the cause is the laxity of the eyelids by aging.

The spastic entropion, often unilateral, can be demonstrated by asking the patient to strongly close the eyelids, which unmasks the winding inside.

When entropion is permanent, its diagnosis is easier.

The treatment is surgical.

Ectropion:

Conversely, ectropion is constituted by eversion, that is to say rotation to the outside of the lower eyelid. It is accompanied by tearing when the lower punctum is no longer in contact with the lacrimal river and redness or keratinization of the exposed palpebral conjunctiva.

The treatment is surgical.

Episcleritis:

The episcleritis can also cause severe pain. The redness is localized unilateral, sometimes flat and sometimes as a red nodule, visible “in the white of the eye”, and without secretion. The main causes of episcleritis are rheumatoid arthritis, Wegener’s disease and chronic polychondritis, Takayasu’s arteritis, and kidney disease IgA (Berger’s disease).

The treatment is local NSAIDs. Steroids are avoided because that could cause the judgment rebound.

Scleritis are much rarer and involve patients with systemic disease, especially rheumatoid arthritis inadequately controlled with systemic treatment.

Painful Blind Eye:

The blind eye following ocular polypathologies (absolute glaucoma, neovascular glaucoma, endophthalmitis, tumor, trauma, retinal detachment, eye phtyse, infection, uveitis or after interventions) may become painful (acute exacerbations background chronic pain).

The pain may require a retrobulbar injection of Xylocaïne® and ethanol or a radical surgical treatment (enucleation in case of suspected tumor, if evisceration allowing better adaptation of cosmetic prosthesis).

WITH ACUTE PAIN ASSOCIATED PUPILLARY ANOMALY OR NOT eyelid ACHIEVED:

These are neurosurgical emergencies. It is important to know how to analyze the pupils in light and darkness (cf. chapter pupillary anomaly).

Unilateral mydriasis with ptosis and diplopia:

Pain with unilateral mydriasis with ptosis and diplopia (most movements are paralyzed and the eye is found in abduction, that is to say divergence) signed an infringement of III.

Any infringement of painful III is urgently seeking an arterial aneurysm of the posterior communicating, trying to crack.

Must refer the patient in emergency neurosurgical environment for neuroimaging and possible embolization.

Myosis:

Painful miosis are correctly detected in low light. Indeed, the pupil on the side of the pain does not expand in the dark, making the maximum in the dark anisocoria. The miosis association, ptosis and enophthalmos (the latter often being very discreet) characterizes Horner syndrome.

All painful Horner syndrome must seek a carotid dissection. Carotid dissection is associated in two thirds of cases of ipsilateral headache, and in 10% of cases, pain in the eye, face or ear, without headache.

Support is urgently with imagery and put under anticoagulant. Indeed, the dissection of the wall constitutes a hindrance to the flow with a risk of ischemic stroke.

This chapter will not treat headache with eye projection, or the typical trigeminal neuralgia (presence of a trigger zone in 50% of cases, with vegetative symptoms (tearing) in 30% of cases).

CHRONIC PAIN:

Chronic pain is very common and are variously expressed by the patient.

Their character, most of the time Benin, is confi rmed by the absence of long term evolution.

Simple questioning classifies these diseases that fill the waiting rooms of ophthalmologists: it burns and it itches (itch)?It stings ? It hurts behind the eye?

Meibomianitis:

The patient complains of pain behind the eye that burns ( “it burns and it hurts behind the eye”). This eye pain is frequently reported in consultation.

Meibomian glands are special sitting sebaceous glands in the eyelids, in the tarsus, and opening on the free edge of the back of the eye lash line. They secrete a lipid substance that participates in the composition of the tear film, making, in particular, more resistant to breakage by evaporation of the aqueous component.

Normally the substance is liquid, transparent and flows spontaneously during eyelid blinking.

In chronic meibomianitis, lipid secretions are abnormally thicker (to varying degrees depending on the patient, which is easily observed at the slit lamp) and will be blocked within the glands.

There is a frothy tears on the lid margins and “secretions” soft chronic or become hard after drying, remove two or three times a day from the corner of the eye.

Chronic inflammation and telangiectasias of the free edge are associated. Some advanced cases can be complicated by corneal neovascularization lesions, typically the lower limb, and require oral treatment under the guidance of a dermatologist.

Meibomianitis within the scope of ocular rosacea. It is very common but often unrecognized. He often combines them dry eye (see above). Skin lesions of rosacea, formerly known as rosacea, rosacea combines more or less papulopustules in the midline of the face, then in the late stage rhinophyma unsightly and final.

Functional signs:

Functional signs meibomianitis are due a hyperpression inside glands that often generates a feeling of pain, often described as “behind the eye” and often asymmetrical. This pain can be reproduced by pressure free lid margins higher against the eye. It is recognized by the patient as being equivalent to the pain spontaneously.

At most, if completely blocked, the gland continues to secrete a chalazion (commonly referred to as “crony Loriot”) is formed. It should not be confused with the stye, much rarer, a boil a ciliary follicle.

Ocular burning gladly accompanies chronic meibomianitis. Indeed, the tear film is not sufficiently “oiled” by the prisoner remained lipid substance in eyelid sebaceous glands, it is unstable. In all circumstances where there is a rarity willingly blinking (eg watching television, in front of the computer screen, etc.), the tear film breaks early and gives the sensation of ocular burn. The advice is to subject themselves voluntarily to blink and better hydrated. The dry atmosphere of air conditioning is often disputed.

Treatment :

The primary treatment is the cause and is a lid hygiene. Take the time to explain to the patient (see Box 2). Wetting eye drops are useful, provided that you use only preservative-free eye drops. The Conservatives have a detergent effect on lipids in the tear film, which aggravates the problem and lead to long alteration on conjonctivocornéen epithelium).

Box 2. Eyelid Hygiene
The lid hygiene threefold. The goal is to help the meibomian glands to excrete the products of their secretion (in analogy with butter melting heat):
1 – Flush eyes with saline pods 5mL (available in pharmacies or supermarkets), with a dozen drops in each eye.
This allows to hunt lipid debris infl ammation generators to the ocular surface and other potential pollutants or allergens and provides the conditions for a better functioning of the ocular surface.
2 – It takes heat eyelids to fl er uidifi oily secretions meibomian and facilitate their evacuation. The classic method is to use a clean washcloth, previously soaked in hot water, then wring out and apply to closed eyelids.The operation is repeated every one to two minutes, reheating the washcloth being assured in the same way, so to achieve a heater 5 to 10 minutes.
3 – It is necessary to press the lid margins (up eyelashes) with the pulp of the index finger or thumb maintaining pressure (firm but extended) against the eye.
The entire length of the eyelid and should be treated methodically, ideally until you feel that the lid margin became softer, thinner.
During these maneuvers, avoid exercising lateral movements on the eyelids, which might loosen them and harm their prematurely élasticité.La meibomianitis being chronic and permanent, the eyelid care are indeed care of hygiene and must be pursued and daily life.
Please note, contact lenses should be removed during this procedure because of the risk of infection (amoeba) due to water.
There are many other more practical methods to raise the temperature of the eyelids. For example, enjoy the warmth of the water in the shower to apply several fingers warmed up against the closed eye (without contact lenses), which concentrates the heat quickly and maintain pressed against the eye without exerting any lateral movements. Methods without water can make profi t the heat from a hot bowl or heater, to transfer through the palms or fingertips. The key is to find a method that works, acceding and practice.

Keratitis / keratoconjunctivitis can be associated to lysis of neutral lipids by exoenzymes lipolytic of bacterial origin, resulting in an elevation of the levels of free fatty acids in the tears. If corneal complications, conjunctival synechiae, it may be appropriate to prescribe cyclins orally over several months.

Seborrheic blepharitis crusted less common, may require the application of a gel or ophthalmic ointment antistaphylococcal for about a week.

Eyestrain:

When pain (headaches, eye fatigue) is punctuated by activity and visual stress, increased late in the day, typically absent on awakening, less during weekends and holidays, we must think of a difficulty in ‘accommodation (for example, unpaid or insufficiently corrected hyperopia, uncorrected astigmatism) or a convergence insufficiency.

Heterophoria may tend to decompensate: letters and lines mingle after 10 to 15 minutes of reading.

The ophthalmologist checks refraction, corrects visual defects and, if applicable, detects a convergence failure. The orthoptist makes orthoptique balance and lead rehabilitation.

Eye burning sensation:

Pain, fatigue or discomfort occur when working on screen or watching television. These are situations where you blink less and where, when the quality of the tear film is not optimal, the “dry” eye. Typically the patient complains of burning.

We must educate the patient to blink voluntarily and well hydrated. Preservative-free wetting eye drops can bring relief.

Think about positioning the lower screen as the eye (blinking is more frequent and complete the look down in the look up). Do not forget the lid hygiene (see Box 2).

Eye tingling sensation:

Meibomian gland dysfunction:

The patient complained of a tingling sensation in the eye ( “it stings, it’s like I had sand in the eyes”). Eyes cry a lot, especially in the cold and wind.

Paradoxically, be aware that dry eye may manifest as a reaction tearing.

Thus, in the dysfunction of the meibomian glands, qualitative alteration of the tear film default lipid layer results in excessive evaporation of tear film, resulting in irritation and producing a reflex too much of aqueous portion of tears.Sometimes, the discomfort is important awakening with difficulty or discomfort at the opening of the eyelids.

On examination with the slit lamp, the lacrimal rivers are reduced or absent and spoof of fine debris (stagnating for lack of flow).

The lid margins, conjunctiva, and even the cornea (superficial punctate keratitis [KPS]) can take marking with fluorescein or green Lissamine (which replaced the rose bengal test).

The treatment is the same as meibomiites.

Sjögren’s syndrome:

The dry eye by a primary or secondary Sjögren’s syndrome is responsible for a major reduction in tear secretion by the lacrimal glands. A dry mouth is often associated with it. Functional symptoms and physical signs of dry eye are the same, but often with increased occurrence of filamentous keratitis.

The Schirmer test is typically close to the lack of secretion (pay attention to the wet blotting paper before ablation to power off the smooth conjunctiva). This test is universally distributed, but more measures the volume of the lacrimal river that runs along the lid margins that the reality of the secretory flow. The biopsy of the salivary glands allows accessories alone to establish the diagnosis by showing a lymphoplasmacytic infiltration of the glandular tissue (codified ed into degrees of greater or lesser damage: classification Chisolm).

Treatment often requires rinsing with saline and the use of preservative free eye drops containing sodium hyaluronate, or even occlusion meatus by punctal nails. He joins an oral treatment (pilocarpine as Salagen®; hydroxychloroquine 400 mg / day).

Eye droughts:

The two causes of dry eye, decreased secretion and increased evaporation, can be combined. Lacrimal rivers are reduced and residues stagnating and concentrate there. The osmolarity of the tear film increases and corneal and conjunctival changes appear.

Rinse by a dozen saline drops is important to remove irritants and debris reduce the osmolarity. In addition, most patients need to tear substitutes. Wetting eye drops, provided that no preservatives, are in order.

Preservatives degrade the ocular surface by their detergent effect of increasing the qualitative defect of the surface lipid layer and induce a chronic inflammation. Therefore should only be prescribed, that unitary pods ( “single dose”), or multiple dose vials specifically designed to be conservative.

Other tips: hydrate, think to blink, to lower the computer screen.

Itching of the eye:

Itching of the eye ( “it itches”) is fairly typical of the discomfort of allergic conjunctivitis, as a rule, bilateral. Itching is notable. Sometimes the disease is very acute with chemosis (edema and swelling of the conjunctiva), but more often it is chronic.

The eyes may not be red. The key word is pruritus.

Local treatment is very effective and, relieving rapidly consolidating post diagnosis.

Rinse eyes with saline improves symptoms already washing the allergens (advisor to the minimum to wash and rinse the face). Eye drops used, preferably without preservatives, are allergy or local antihistamines or generals.

CONCLUSION:

The most benign causes of chronic ocular discomfort are by far the most frequent causes. The advice (lid hygiene, crowding preservatives, etc.) are important to convey to many.

The obviously purely ocular acute pain are addressed to the ophthalmologist, in extreme urgency for serious diagnoses (endophthalmitis, acute glaucoma attack, red eye in a wearer of soft contact lenses, corneal abscesses, etc.).

Pain with tumor syndrome should be managed in a specialized environment. The typical neurological pain must be in neurology.

The pain that it is important not to ignore are those accompanied by pupillary abnormalities (miosis in darkness, mydriasis) ipsilateral because they are of vital significance (carotid dissection and intracranial aneurysm cracking respectively) and must be immediately supported in specialized areas (see pupillary abnormalities).

Conversely, a patient who complains of a recent pupillary defect, the examination is to track down the least pain to not overlook these two diagnoses.