Osman Haji
Most acute ophthalmic conditions, such as painful red eye, overt ocular trauma, or sudden loss of vision, are readily recognised at triage and diverted directly to eye casualty or urgent ophthalmology services. These classic presentations follow established pathways and seldom require extensive diagnostic work from Emergency Department (ED) clinicians beyond initial assessment and analgesia.
However, a significant minority of vision-threatening disorders do not declare themselves in an obviously ocular manner. Instead, they present with systemic, neurological, or facial symptoms and are therefore assessed initially in general ED areas rather than specialist ophthalmic pathways. These atypical presentations can easily be misattributed to more common non-ophthalmic conditions, delaying diagnosis and risking permanent visual morbidity. The following sections outline key ophthalmic diseases that disproportionately present to the ED because their first manifestation is not recognised as ophthalmic at all.
Headache Presentations With an Ophthalmic Aetiology
Headache is a ubiquitous ED complaint, yet several ophthalmic emergencies masquerade as primary headache disorders. Acute angle-closure glaucoma (AACG) is a prime example. Patients often present with severe frontal or peri-orbital headache, nausea, vomiting, or photophobia, causing triage staff to categorise the case as suspected migraine or intracranial pathology rather than an eye problem. Only detailed questioning or careful examination reveals the subtle early ocular features: blurred vision, haloes around lights, mild pupillary dilation, or corneal oedema. Because AACG can cause rapid, irreversible optic nerve damage, ED-initiated therapy (systemic acetazolamide and topical pressure-lowering agents) is essential before definitive ophthalmic management.
Similarly, giant cell arteritis (GCA) frequently enters the ED as a general medical or neurological complaint rather than an ophthalmic emergency. Patients report new-onset temporal headaches, scalp tenderness, constitutional symptoms, or jaw claudication. Visual symptoms may be transient or only disclosed when specifically sought. Yet the ophthalmic consequences, most notably anterior ischaemic optic neuropathy are profound and time-critical. ED clinicians must recognise the risk of irreversible visual loss and death and initiate high-dose corticosteroids immediately upon clinical suspicion, even before definitive diagnostic testing.
Neurological-Type Presentations With Ophthalmological Significance
Another group of ophthalmic disorders commonly encountered in the ED comprises those presenting as possible neurological emergencies. Third nerve palsy, for example, typically presents with acute ptosis or diplopia, which may prompt stroke or neurosurgical pathways rather than eye casualty referral. The eye may appear externally normal, and the diagnosis hinges on careful assessment of ocular motility and pupillary involvement. A pupil-involving palsy raises the possibility of a compressive posterior communicating artery aneurysm and mandates urgent neuroimaging before ophthalmic assessment (1).
Optic neuritis presents similarly ambiguously. Patients describe subacute unilateral visual loss, impaired colour vision, or pain on eye movement. These are symptoms that may be misattributed to sinus disease, migraine with aura, or general neurological disorder. The detection of a relative afferent pupillary defect or characteristic dyschromatopsia is often the ED clinician’s key to recognition and timely referral for neuro-ophthalmic evaluation.
Facial Pain and ENT-Type Presentations With Underlying Ocular Pathology
Atypical ophthalmic pathology is also commonly hidden beneath facial or dental pain. Herpes zoster ophthalmicus (HZO) often begins with isolated neuropathic pain in the ophthalmic branch of the trigeminal nerve, with no rash or ocular signs at presentation (2). Such patients are naturally triaged to general ED or ENT/dental streams rather than to eye casualty. Early antiviral therapy initiated in the ED, before the eruption of vesicles, can significantly reduce ocular morbidity (3).
Similarly, early orbital cellulitis may initially manifest as deep facial pain, headache, or vague peri-orbital discomfort, before the appearance of classical signs such as proptosis, ophthalmoplegia, or visual decline (4). These patients are frequently misdirected to ENT or general medical pathways. However, because these conditions can progress rapidly to cavernous sinus thrombosis or intracranial involvement, the ED clinician must maintain a high index of suspicion when pain or cranial neuropathies seem disproportionate to external findings.
Non-Ocular Presentations That Reveal Ocular Disease
Finally, several significant ophthalmic conditions present in ways that do not immediately suggest eye involvement. Retinal detachment may come to attention through complaints of imbalance, falls, or generalised visual “difficulty,” especially in older adults who may not volunteer unilateral visual distortion unless specifically asked. Because the prognosis worsens sharply once the macula detaches, ED-based visual acuity testing and prompt suspicion are crucial.
Amaurosis fugax is another frequently under-recognised ophthalmic manifestation. Patients may describe transient monocular blackout as “dizziness,” “near-collapse,” or a brief neurological episode, prompting triage to general or stroke pathways. Identifying its monocular nature reclassifies the presentation as an ophthalmic vascular warning sign. This recognition is critical because amaurosis fugax often indicates underlying carotid disease and signals a substantial risk of stroke.
Conclusion
While classic ophthalmic presentations are typically triaged directly to eye casualty, many severe ophthalmic conditions first appear in the Emergency Department precisely because their initial manifestations are not overtly ocular. These atypical presentations such as headache, facial pain, diplopia, transient neurological symptoms, or unexplained functional decline, require ED clinicians to exercise diagnostic vigilance and maintain an expanded differential diagnosis. Early recognition and initiation of appropriate interventions in the ED can profoundly influence visual and systemic outcomes. For non-ophthalmology clinicians, understanding these atypical patterns is an essential component of acute care practice.
References
- MOTOYAMA Y, NONAKA J, HIRONAKA Y, PARK YS, NAKASE H. Pupil-Sparing Oculomotor Nerve Palsy Caused by Upward Compression of a Large Posterior Communicating Artery Aneurysm. Neurologia medico-chirurgica [Internet]. 2012 [cited 2025 Mar 13];52(4):202–5. Available from: https://pubmed.ncbi.nlm.nih.gov/22522330
- Lee HL, Yeo M, Choi GH, Lee JY, Kim JS, Shin DI, et al. Clinical characteristics of headache or facial pain prior to the development of acute herpes zoster of the head. Clinical Neurology and Neurosurgery [Internet]. 2017 Jan 1 [cited 2020 Oct 28];152:90–4. Available from: https://www.sciencedirect.com/science/article/pii/S0303846716304206
- Minor M, Payne E. Herpes zoster ophthalmicus [Internet]. PubMed. Treasure Island (FL): StatPearls Publishing; 2023. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557779/
- Kyari F. Emergency management: orbital cellulitis. Community Eye Health [Internet]. 2018 Nov 9;31(103):60. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6253316/