A patient presents with eye pain and redness. Does palpation help raise or lower the probability of acute glaucoma?  Is this physical examination finding worth pursuing?

First, it should be stated that many physical findings we pursue lack sufficient specificity to rule in a diagnosis.  Others lack the sensitivity to rule it out.  Palpation of globe pressure has not been studied prospectively as a physical finding in the acute painful eye population.

However, many opthalmologists consider it a useful finding.  If one palpates an asymmetrically rock hard globe on one side then the differential diagnosis can be narrowed substantially.  All that is required is confirmation through tonometry.

It is reasonable for emergency physicians to cultivate this as a bedside skill.  Have the patient look down, and palpate the superior portion of the globe through a closed lid.  See how much force is required to indent the wall. (Heidary 2010).  Use tonometry as the gold standard and hone your skills.

Update: Since first writing this post I heard from a colleague who had a severe trauma patient with GCS 3 and proptosis. Ocular palpation led her to the diagnosis of orbital compartment syndrome. During lateral canthotomy she had trouble with the inferior cantholysis, and again it was the palpation that led her to keep going until the eye softened and she was assured of successful release of pressure.


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