The Wills Eye Manual

Chapter 1. Differential Diagnosis of Ocular Symptoms


More Common. Blepharitis, meibomitis, dry eye syndrome, conjunctivitis.

Less Common. Inflamed pterygium or pinguecula, episcleritis, superior limbic keratoconjunctivitis, ocular toxicity (medication, makeup, contact lens solutions), contact lens-related problems.


See 8.4, Esodeviations (eyes turned in), or 8.5, Exodeviations (eyes turned out).


1. Monocular

• Acute

Painless. Retinal artery or vein occlusion, ophthalmic artery occlusion, ischemic optic neuropathy, giant cell arteritis, vitreous hemorrhage, retinal detachment, sudden discovery of preexisting unilateral visual loss.

Painful. Corneal lesion (abrasion, ulcer), uveitis, dry eye syndrome, acute angle-closure glaucoma, endophthalmitis, corneal hydrops, optic neuritis (pain with eye movement; however, ~ 10% of cases are painless).

 Transient (vision returns to normal within 24 hours)

Painless. Amaurosis fugax, optic disc drusen, impending central retinal vein occlusion (CRVO), ocular ischemic syndrome, orthostatic hypotension.

Painful. Migraine, dry eye syndrome, superficial punctate keratopathy.

2. Binocular

 Acute and/or transient

Painless. Stroke (homonymous hemianopsia), vertebrobasilar insufficiency, ciliary spasm or ciliary body rotation, papilledema.

Painful. Migraine, dry eye syndrome, superficial punctate keratopathy, pituitary apoplexy, papilledema (may have headache).

3. Monocular/binocular


Painless. Refractive error, cataract, open angle glaucoma, chronic angle-closure glaucoma, corneal scar, optic neuropathy, dry eye syndrome, chronic retinal disease (e.g., diabetic retinopathy, age- related macular degeneration [AMD]).

Painful. Dry eye syndrome, superficial punctate keratopathy.

4. Posttraumatic visual loss: Corneal irregularity, hyphema, ruptured globe, traumatic cataract, commotio retinae, retinal detachment, retinal or vitreous hemorrhage, lens dislocation, traumatic optic neuropathy, cranial neuropathies, central nervous system (CNS) injury, sympathetic ophthalmia (rare).

NOTE: Although a diagnosis of exclusion, remember to consider nonphysiologic vision loss.


See “Red Eye” in this chapter.


More Common. Refractive error including astigmatism (e.g., from anterior segment surgery, periorbital or eyelid edema/mass [e.g., chalazion, orbital trauma]), macular disease (e.g., central serous chorioretinopathy, macular edema, and AMD), corneal irregularity (e.g., keratoconus, epithelial basement membrane dystrophy), corneal opacity, intoxication (e.g., ethanol, methanol).

Less Common. Pellucid marginal degeneration, post-refractive surgery corneal ectasia, topical eye drops (e.g., miotics, cycloplegics), retinal detachment, migraine (transient), hypotony, pharmacologic (anticholinergic medications), and nonphysiologic.


1. Monocular (diplopia remains when the uninvolved eye is occluded)

More Common. Refractive error, incorrect spectacle alignment, corneal opacity or irregularity including keratoconus, cataract, iris defects (e.g., iridectomy), dry eye syndrome, superficial punctate keratopathy.

Less Common. Dislocated natural lens or lens implant, macular disease, CNS causes (rare), nonphysiologic.

2. Binocular (diplopia eliminated when either eye is occluded)

 Typically intermittent: Myasthenia gravis, intermittent decompensation of an existing phoria.

 Constant: Isolated sixth, third, or fourth cranial nerve palsy; orbital disease (e.g., thyroid eye disease, carotid cavernous sinus fistula); cavernous sinus syndrome; status-post ocular surgery (e.g., residual anesthesia, displaced muscle, muscle surgery, restriction from scleral buckle, severe aniseikonia after refractive surgery); status-post trauma (e.g., orbital wall fracture with extraocular muscle entrapment, orbital edema); convergence/divergence insufficiency; internuclear ophthalmoplegia; vertebrobasilar artery insufficiency; other CNS lesions; spectacle problem.


See 4.3, Dry Eye Syndrome.


Trauma, burn, cutaneous neoplasm (e.g., sebaceous carcinoma), eyelid infection or inflammation, radiation, chronic skin disease (e.g., alopecia areata), trichotillomania.


More Common. Blepharitis, meibomitis, conjunctivitis.

Less Common. Canaliculitis, nasolacrimal duct obstruction, dacryocystitis.


See 6.1, Ptosis.


1. Associated with inflammation (usually erythematous and tender to palpation).

More Common. Hordeolum, blepharitis, conjunctivitis, preseptal or orbital cellulitis, trauma, contact dermatitis, herpes simplex or varicella zoster dermatitis.

Less Common. Ectropion, corneal pathology, urticaria or angioedema, insect bite, dacryoadenitis, erysipelas, eyelid or lacrimal gland mass, autoimmunities (e.g., discoid lupus, dermatomyositis).

2. Noninflammatory: Chalazion; prolapse of orbital fat; eyelid or lacrimal gland mass; foreign body; cardiac, renal, or thyroid disease; superior vena cava syndrome; festoons.


Orbicularis myokymia (related to fatigue, excess caffeine, medication, or stress), corneal or conjunctival irritation, dry eye syndrome, blepharospasm (bilateral), hemifacial spasm, Tourette syndrome, tic douloureux, albinism/congenital glaucoma (photosensitivity).


Severe proptosis, ectropion or eyelid laxity, severe chemosis, eyelid scarring, eyelid retractor muscle scarring, seventh cranial nerve palsy, status-post botulinum toxin injections, after facial cosmetic or reconstructive surgery, thyroid eye disease.


See 7.1, Orbital Disease.


Acquired nystagmus, internuclear ophthalmoplegia, myasthenia gravis, vestibular function loss, opsoclonus/ocular flutter, superior oblique myokymia, various CNS disorders.


More Common. Posterior vitreous detachment, retinal break or detachment, migraine, rapid eye movement (particularly in darkness), oculodigital stimulation, dysphotopsias from an intraocular lens.

Less Common. Retinitis/uveitis (e.g., white dot syndromes), CNS (particularly occipital lobe) disorders, vestibulobasilar artery insufficiency, optic neuropathies, entoptic phenomena, drug-related, hallucinations, iatrogenic (e.g., after laser photocoagulation).


See “Spots in Front of the Eyes” in this chapter.


Dry eye syndrome, blepharitis, conjunctivitis, trichiasis, corneal or conjunctival abnormality (e.g., abrasion, erosion, foreign body, loose/broken suture, exposed suture tail/tube/buckle/hardware, conjunctival cyst, recurrent corneal erosion, superficial punctate keratopathy), contact lens-related problem, episcleritis, pterygium, pinguecula, postoperative.


Cataract, pseudophakia, posterior capsular opacity, corneal edema or opacity, pharmacologic dilation, altered pupillary structure or response, status-post refractive surgery, posterior vitreous detachment.


Posterior vitreous detachment, retinal or choroidal detachment, optic neuropathies, blindness or bilateral eye patching (i.e., Charles Bonnet syndrome), psychosis, parietotemporal lesions, other CNS causes, medications.


Cataract, pseudophakia, posterior capsular opacity, corneal edema from acute angle-closure glaucoma or other causes (e.g., Fuchs dystrophy, aphakic or pseudophakic bullous keratopathy, contact lens overwear), corneal dystrophies, corneal opacity, status-post refractive surgery, discharge, dry eye syndrome, superficial punctate keratopathy, pigment dispersion syndrome, vitreous opacities, drugs (e.g., digitalis, chloroquine).


See 10.26, Headache.


Conjunctivitis (especially allergic, atopic, and viral), blepharitis, dry eye syndrome, contact dermatitis, giant papillary conjunctivitis, contact lens-related problems.


1. Abnormal eye examination

More Common. Corneal abnormality (e.g., abrasion, ulcer, edema), anterior uveitis.

Less Common. Conjunctivitis (mild photophobia), posterior uveitis, scleritis, albinism, aniridia, total color blindness, mydriasis of any etiology (e.g., pharmacologic, traumatic), congenital glaucoma.

2. Normal eye examination: Migraine, meningitis, concussion, retrobulbar optic neuritis, subarachnoid hemorrhage, trigeminal neuralgia, lightly pigmented irides.


More Common. Refractive error (especially undercorrected myopia), advanced glaucoma or optic atrophy, miosis (especially pharmacologic), retinitis pigmentosa, congenital stationary night blindness, after panretinal photocoagulation, drugs (e.g., phenothiazines, chloroquine, quinine).

Less Common. Vitamin A deficiency, gyrate atrophy, choroideremia.


1. Ocular:

 Typically mild to moderate: Dry eye syndrome, blepharitis, infectious conjunctivitis, episcleritis, inflamed pinguecula or pterygium, foreign body (corneal or conjunctival), superficial punctate keratopathy, superior limbic keratoconjunctivitis, ocular medication toxicity, contact lens-related problem, postoperative, ocular ischemic syndrome, eye strain from uncorrected refractive error (asthenopia).

 Typically moderate to severe: Corneal disorder (e.g., abrasion, erosion, infiltrate/ulcer, chemical injury, ultraviolet burn), trauma, anterior uveitis, scleritis, endophthalmitis, acute angle-closure glaucoma.

2. Periorbital: Trauma, hordeolum, preseptal cellulitis, dacryocystitis, dermatitis (e.g., contact, chemical, varicella zoster, or herpes simplex), referred pain (e.g., dental, sinus), giant cell arteritis, trigeminal neuralgia.

3. Orbital: Trauma, sinusitis, orbital cellulitis, idiopathic orbital inflammatory syndrome, orbital tumor or mass, optic neuritis, acute dacryoadenitis, migraine or cluster headache, microvascular cranial nerve palsy, postherpetic neuralgia.

4. Asthenopia: Uncorrected refractive error, phoria or tropia, convergence insufficiency, accommodative spasm, pharmacologic (miotics).


1. Adnexal causes: Trichiasis, distichiasis, floppy eyelid syndrome, entropion or ectropion, lagophthalmos, blepharitis, meibomitis, acne rosacea, dacryocystitis, canaliculitis.

2. Conjunctival causes: Ophthalmia neonatorum (in infants), conjunctivitis (infectious, chemical, allergic, atopic, vernal, medication toxicity), subconjunctival hemorrhage, inflamed pinguecula, superior limbic keratoconjunctivitis, giant papillary conjunctivitis, conjunctival foreign body, symblepharon and associated etiologies (e.g., mucous membrane pemphigoid, Stevens-Johnson syndrome, toxic epidermal necrolysis), conjunctival neoplasia.

3. Corneal causes: Infectious or inflammatory keratitis, contact lens-related problems (see 4.20, Contact Lens-Related Problems), corneal foreign body, recurrent corneal erosion, pterygium, neurotrophic keratopathy, medicamentosa, chemical or ultraviolet burn.

4. Other: Trauma, postoperative, dry eye syndrome, anterior uveitis, episcleritis, scleritis, endophthalmitis, pharmacologic (e.g., prostaglandin analogs), angle-closure glaucoma, carotid- cavernous fistula (corkscrew conjunctival vessels), cluster headache.


1. Transient: Migraine.

2. Persistent:

More Common. Vitreous syneresis, posterior vitreous detachment, vitreous hemorrhage, intermediate or posterior uveitis.

Less Common. Hyphema/microhyphema, retinal break or detachment, corneal opacity, or foreign body.

NOTE: Some patients are referring to a blind spot in their visual field caused by a retinal, optic nerve, or CNS disorder.


1. Adults

 Pain present: Corneal abnormality (e.g., abrasion, erosion, foreign body or rust ring, edema), anterior uveitis, eyelash or eyelid disorder (e.g., trichiasis, entropion), conjunctival foreign body, dacryocystitis, dacryoadenitis, canaliculitis, trauma.

 Minimal/no pain: Dry eye syndrome, blepharitis, nasolacrimal duct obstruction, punctal occlusion, lacrimal sac mass, ectropion, conjunctivitis (especially allergic and toxic), crocodile tears (congenital or seventh cranial nerve palsy), emotional state.

2. Children: Nasolacrimal duct obstruction, congenital glaucoma, corneal or conjunctival foreign body, other irritative disorder.