Photophobic or Over Sensitive?

Bright light. It’s horrible. Who does like looking at bright light? I don’t. So when a patient presents with a chief complaint of photophobia, what are we meant to do?

I have had two cases in the last two weeks.  The first was a student who felt that his photophobia had got progressively worse over a week and was now wearing sunglasses in class. The second was a middle aged gentleman whose eyes were so sensitive that even the thought of ophthalmoscopy made his eyes close tightly.

It seems to me to be too easy to dismiss these symptoms, but is that in the best interests of the patient?  As practitioners, what should we be checking? What methods of investigation be should we employ?  Which conditions jump into our mind?

I see ‘photophobia’ as a symptom that few suffer from, as a symptom of an underlying pathological condition. Photosensitivity, however is widely recognised. However for all but a few individuals there is actually very little wrong.  But where there is an underlying condition, the consequences are serious, especially if we miss it.

In both of my cases, visual acuities were 6/6 or 6/5. The main difference between them was that the student’s ‘photophobia’ was a new symptom but the middle aged man’s symptoms were long standing.

I proceeded to check for retinitis pigmentosa (waxy discs, attenuated vessels, pigmented spicules (although this is not always present), acute angle closure glaucoma (pressures, Van Herrick’s angles), iritis (cells and flare, redness), corneal pathology (fluorescein staining, slit lamp examination) as well as a host of other things, all which proved negative.

As each day passes, there are many unanswered symptoms. But at what point do I stop running late and give up looking for the answer?  Sometimes there may not be an answer? How far do we have to go to ensure we have ensured our safe passage away from negligence?

What would be best practice in these cases?

Comments

  1. Hi Peter,
    It seems like you have already done all the test any other optometrist would also do in your situation. The only other investigation is visual fields ( full field test).
    I have encountered similar patients with these symptoms before and learnt (working with a consultant ophthalmologist) that a thorough investigation on migraines and family history of migraine should be noted. There ar some forms of optical migraine that can cause photophobia as its only symptom. As we all know some migraines can last for days to even months and can be very distressing for the patient. I advise after all tests being negative to refer them to a neurologist with ophthalmic interest. Also a follow up in 6months would not only benefit your patient but also aid your learning as to get feedback from the further investigations.
    Good luck and keep us all posted!
    Shagufta

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