A 70-year-old man is brought by his son because his right eye has been constantly aching for months. The eye has been blind for years from glaucoma that was never treated — he stopped attending clinic when his vision faded. The pain is a deep ache, worse at night, and ordinary painkillers barely help. The left eye sees 6/12 with advanced field loss.
Examination Findings
Right eye: no perception of light, pressure 55 mmHg, cornea oedematous and hazy, pupil fixed and mid-dilated, optic disc pale and deeply cupped. The eye is not red and there is no discharge. B-scan ultrasound shows no mass behind the lens. Left eye: pressure 28 mmHg, cup 0.9, constricted field — advanced but still seeing.
Investigations
B-scan ultrasound of the blind eye is important: a blind painful eye can harbour an intraocular tumour, and that must be excluded before destructive procedures. Assess the left eye fully — fields, disc imaging — because it is the seeing eye and needs urgent pressure control.
Questions to Think About
- Why is pain relief, not vision, the goal in the right eye?
- Why must a tumour be excluded first?
- What does this case teach about the left eye?
Diagnosis
Absolute glaucoma of the right eye (blind, painful, end-stage) with advanced primary open-angle glaucoma of the left eye.
Reasoning
Reasoning: This is absolute glaucoma — end-stage disease where the optic nerve is dead, the pressure is very high, and the cornea and ciliary body generate chronic pain. No treatment can restore vision to an eye with no light perception and a pale, excavated disc, so every decision is about comfort and cosmesis. A blind painful eye is also the classic presentation of an occult intraocular tumour (such as a melanoma causing secondary glaucoma), so B-scan exclusion of a mass is mandatory before any destructive or comfort procedure. Diagnosis: absolute (end-stage) glaucoma of the right eye with chronic pain; advanced primary open-angle glaucoma of the left. Management: typical management includes comfort-directed measures for the blind eye — cyclodestructive procedures to lower pressure and reduce pain, and, if pain remains intractable, discussion of evisceration or enucleation with the patient and family — while the seeing left eye gets urgent, aggressive pressure lowering to preserve its remaining field. The deeper lesson is the one the son takes home: glaucoma treatment must continue even after vision fades, because stopping is what created this situation.
Differential Diagnosis
- Acute angle closure — ruled out: chronic course over months, a blind eye, no mid-attack signs.
- Neovascular glaucoma — ruled out: no rubeosis iridis and no retinal ischaemic driver found.
- Intraocular tumour with secondary glaucoma — excluded by B-scan; it must always be considered in a blind painful eye.
Management
Typical management includes pain-directed treatment for the blind eye: pressure reduction by cyclodestructive laser, and if pain persists, surgical options including evisceration or enucleation discussed sensitively with the patient and family. Meanwhile the seeing eye receives full glaucoma therapy — drops, laser or surgery — to protect its remaining vision. Counselling addresses the grief of lost vision and the importance of adherence for the fellow eye.
Key Learning Points
- Absolute glaucoma is defined by no useful vision plus uncontrolled pressure, often with chronic pain.
- Comfort becomes the goal: cyclodestruction first, evisceration/enucleation only for intractable pain.
- Every blind painful eye needs a B-scan to exclude tumour.
- The real tragedy is preventable — continued treatment preserves the fellow eye.
Red Flags
- A blind painful eye — exclude an intraocular tumour with B-scan before any destructive procedure.
- Stopping treatment when vision fades — the commonest route to a painful blind eye.
- The fellow eye in absolute glaucoma — usually advanced too; it needs urgent protection.
Educational content only — not medical advice. Clinical decisions must be made by a qualified professional for the individual patient.
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