Treating acute painful loss of vision

Acute loss of vision associated with pain may be due to infection (corneal ulcer, endophthalmitis); Inflammations (Iritis, optic neuritis); or acute glaucoma.

Corneal Ulcer: An infection of the cornea presenting with pain, redness and cloudiness of the cornea. This may follow contact lens related injury, scratches of the cornea by a fingernail, by a branch in the garden, a foreign body hitting the eye. A corneal ulcer can lead to permanent vision impairment from corneal scarring. Scarring may require treatment by a corneal transplant operation. Infection may spread inside the eye resulting in loss of the eye. Corneal ulcers must, therefore, be seen and treated immediately by an ophthalmologist. You are at risk of developing a corneal ulcer if you suffer an injury to the eye. Treatment for the injury by the Ophthalmologist will prevent corneal infection.
Severe infection of the inside of the eye (endophthalmitis) may follow eye surgery or penetrating injury. It causes blindness by damage to the retina and optic nerve (nerve of sight).

Infection of the tissues behind the eye (orbital cellulitis) is more common in children. This presents with painful swelling of the eye and redness in a sick looking child with lids that are closed. This is an emergency that requires intensive treatment in hospital with injectable antibiotics. It can cause blindness by affecting the optic nerve behind the eye and also has the risk of spreading to the brain. It is therefore life threatening.

Inflammatory (non-infective) Disease of the Eye: Iritis — inflammation of the coloured part of the eye causes pain, redness, blurred vision and glare sensitivity. This condition responds readily to treatment with anti-inflammatory (usually steroid) eye medications. Other medications are used to prevent complications of the inflammation which include glaucoma and cataract.

Inflammation of the front of the eye may also be accompanied by inflammation of the back of the eye. This is usually not painful but may lead to impaired vision due to scarring of the retina. Iritis can follow blunt injury to the eye.

Iritis is also associated with other (systemic) disease that affect other parts of the body eg. rheumatoid arthritis, lupus, and inflammatory disease of the spine.

Other inflammatory diseases associated with vision loss and pain affect the optic nerve (optic neuritis) blood vessels of the temple and optic nerve. This needs prompt treatment to prevent blindness.

Acute angle closure glaucoma

Chronic glaucoma (the common type) leads to slow loss of vision and is painless. Acute glaucoma causes severe eye pains and headaches, associated with nausea and vomiting. There is redness of the eye and blurred vision. If not treated immediately will lead to loss of sight in the affected eye. It occurs when the drainage angle inside the front of the eye becomes blocked. This interferes with the drainage of fluid out of the eye. This fluid (not tears which is on the outside) builds up within causing the eye pressure to suddenly rise. The result is acute angle closure glaucoma which is an emergency.

Acute glaucoma may also occur following eye injury, surgery and the use of certain medications used in treating epilepsy, migraine or for weight loss. Immediate treatment uses

i) medications topically to the eyes, orally (by mouth) and intravenously for the acute problem and

ii) the use of laser treatment or surgery to prevent recurrence.

Any condition of the eye causing pain, redness and blurred vision must be treated as an emergency, by an ophthalmologist. They are sight threatening and in some cases life threatening.

Author: Deo Singh. MB, BS; FRCS; FRCOPhth

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