Case 4

A 64-year-old with nausea and decreased vision


A 64 yo woman presents to the ED with nausea and vomiting of 1 day duration. As an astute EM resident, you note that in her ROS, he complains of headache and decreased vision.

What additional history do you want to obtain?


After you conclude your history and physical examination, your patient asks you what you think is going on.

Which physical examination would you perform?


After you conclude your history and physical examination, your patient asks you what you think is going on.

What is the most likely diagnosis?


You suspect she has acute angle closure glaucoma based on her unilateral painful red eye, her intraocular pressures, and her slit lamp exam.

What is the next best step in management of this patient?


While waiting on the Ophthalmology attending to arrive, what are some methods to help lower IOP in the affected eye.


Acuit angle closure glaucoma is an acute increase in the intraocular pressure (normal is 10-20 mmHg). It is due to sudden blockage of drainage of the aqueous humor. There is no defect in production of aqueous humor. angle closure glaucoma is usually due to widening of the pupil in an anatomically predisposed eye (shallow anterior chamber), and occurs more frequently in people over 60 with a female:male ratio of 3:1. It is more common in Inuits and very rare in blacks.

Acute angle closure glaucoma is characterized by the acute onset of severe eye pain, which may be referred to the jaw, temples, or occiput (via CN V), nausea and vomiting (due to the irritation of CN X), decreased visual acuity and halos, due to corneal epithelial edema secondary to increased pressure. Always ask about prodromal symptoms – patients may have had several mini-attacks before the one that brought them in.

On physical exam, there is a classic triad for acute angle closure glaucoma – unilateral red eye, fixed dilated pupil, and the eyeball is firm to hard on palpation. Other findings include a dull and edematous cornea, and gonioscopy reveals shallow anterior chamber.

Acute angle closure glaucoma is a medical emergency and must be treated immediately. Medical therapy includes IV mannitol to decreased the volume of vitreous humor and thus decrease IOP, IV acetazolamide to decrease production of aqueous humor, then topical miotic agents such as pilocarpine. Immediate relief may be obtained by needling the anterior chamber with a 25G needle and withdrawing a small amount of fluid, but peripheral iridotomy is usually definitive management as it creates a conduit between the anterior and posterior chambers, thus equalizing pressure.