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Seen in the ED: Headache and Eye Pain in a Young Adult Man


The man, in his 30s, has seen 2 specialists, received 2 diagnoses, and is now in the ED for persistent pain that is worsened by eye motion. Can you dx?

History of present illness

A man in his 30s presents to the emergency department with 2 days of ongoing left ocular pain with associated headache. He was seen 2 days ago earlier by a local ophthalmologist and was diagnosed with dry eyes. Yesterday he was seen by your EM colleague and diagnosed with a migraine. He denies any visual disturbance, blurry vision, or double vision, but his pain is worse with eye motion.

Vital signs & physical examination

Vital signs are normal. Physical exam is otherwise normal except for images shown below. Intraocular pressure is 12 mm Hg in each eye (normal <21 mm Hg).

Image above: Fluoresceine enhanced exam with cobalt blue light on the slit lamp

Image above: Fluoresceine enhanced exam with cobalt blue light on the slit lamp

What is the most likely diagnosis?

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