Quiz: Ocular Discomfort, Tearing, and Itching

This 32-year-old female presents with a 2-month history of the left eye appearing smaller and feeling “stuffy”. She notes no visual changes but complains of ocular discomfort, tearing, and itching. She is pregnant and has a history of iridocyclitis one year ago. What could be happening?

14 thoughts on “Quiz: Ocular Discomfort, Tearing, and Itching”

  1. Unfortunately, the case history is quite misleading and feels academic. Many patients can have baseline scleral show, so it can be hard to determine the offender.

    The chief complaint of left, “stuffy” feeling along with tearing/itching, and hx of uveitis (presumed all left eye since laterality wasn’t stated) prompts the examiner to pursue a left-sided focus.

    This case presentation, in its current format, unwittingly supports nullifying the face-value of the chief complaint. While the patient may indeed occasionally mistake a symptom (or even lie!), it’s not the norm, in my humble opinion.

    Some recommendations:
    1) Please clarify the laterality in the history.

    2) The first differential should include “ptosis vs. retraction”, even before jumping to the differential diagnosis.

    3) Further questioning would be useful: Is there lagophthalmos? Could this be pseudo-retraction (Hering’s law, with slightly elevated brows)? Are there punctuate erosions? Are there any motility restrictions?

    4) Exophthalmometry is indicated to rule out early proptosis…this is how real clinic works and should be reflected in the multiple choice questions.

    While I do appreciate the terse information presented in the case, I humbly recommend revising the report to reflect a more accurate history and more thorough exam, especially when the diagnosis contradicts the patient’s complaint altogether.

    • Thank you for your comments Rob. I like when case presentations stimulate discussion like this. This case is in-fact a real patient who was submitted for Cybersight consultation. You are seeing the same information that was presented to our volunteer faculty mentor.

      To address your points:
      (1) The case presentation is 100% representative of the information provided in the consult, including the lack of defined laterality for the “stuffy” feeling, there is nothing contrived or artificial here. As such, just like our volunteer faculty mentor, one must work with the information at hand ,or request additional clarification… a luxury that is obviously not possible when dealing with a quiz format question. Real life is different.
      (2) While sometimes not obvious to the patient, it was readily obvious to the original examining physician as well as the responding volunteer faculty member as to which eye is the “abnormal” eye. As you point out, a patient’s perception of the problem is not always accurate. We see this all the time with cases of palpebral fissure asymmetry and with strabismus cases. To my observation, the eye with visible pathology is relatively obvious and that is one of the key teaching points for this case.
      (3) Agree. Further questioning would be useful and that is exactly what happens when we talk to patients in the clinic or answer Cybersight consultations. The questions you raise are all excellent and valid questions, unfortunately, that is not possible when one is taking a “quiz” such as this. Maybe someday we will have that interactive ability with A.I. but at present you are limited to dealing with the information as presented.
      (4) Yes, exophthalmometry would be a reasonable test to perform. That information was not available with this case and as such it is not presented. As someone who has worked in many hospitals in low- to middle-income countries around the world over the last 25 years, I can tell you that finding a Hertel exophthalmometer in most clinics around the world in not a given… in fact, it is unlikely. Again, we are dealing with the information as available and as presented in a resource-limited setting.

      Again, thank you for your thought provoking comments and the discussion generated. We appreciate the interest.
      Daniel Neely, MD
      Professor of Ophthalmology, Indiana University School of Medicine


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