Case 4

A 64-year-old with nausea and decreased vision

Q1

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?

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[accordion-item title=”Do you have any eye pain? (click to show/hide)”]

Not specifically my eye, but the entire left side of my face hurts pretty bad.

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[accordion-item title=”Do you have any problems with lights? (click to show/hide)”]

Yeah, they’re really bright, and it looks like there’s a ring around them.

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[accordion-item title=”Has anything like this ever happened to you before? (click to show/hide)”]

Well, now that you mention it, I have had several times when my vision has been blurry, but I thought my blood sugar was just low.

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[accordion-item title=”Have you ever had any eye surgery or trauma? (click to show/hide)”]

No, sir. My eyes have always been healthy.

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Q2

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

Which physical examination would you perform?

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[accordion-item title=”External exam? (click to show/hide)”]

The eye is very red with redness extending all the way to the limbus. There is no evidence of trauma. It also feels hard to the touch.

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[accordion-item title=”VA (click to show/hide)”]

Right eye 20/20, Left eye 20/400

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[accordion-item title=”Confrontational visual fields (click to show/hide)”]

Both eyes seem full to confrontation although the left eye is slower.

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[accordion-item title=”Pupils (click to show/hide)”]

Right eye constricts normally. The left eye does not constrict to light and is around 5 mm in diameter

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[accordion-item title=”Extraocular motility (click to show/hide)”]

Eye motions are full on both sides.

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Q3

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

What is the most likely diagnosis?

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[accordion-item title=”Primary open angle glaucoma (click to show/hide)”]

Incorrect: Primary open angle glaucoma usually has an insidious onset without the acute painful attacks seen here. This picture is more typical of acute closed angle glaucoma.

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[accordion-item title=”Acute closed angle glaucoma (click to show/hide)”]

Correct: The acute onset of unilateral painful red eye, fixed mid-dilated pupil, conjunctival injection and elevated intra-ocular pressure are characteristic of angle closure glaucoma.

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[accordion-item title=”Migraine (click to show/hide)”]

Incorrect: While these symptoms could occur in migraines, the eye findings are typical for angle closure glaucoma.

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[accordion-item title=”Iritis (click to show/hide)”]

Incorrect: Iritis is an important cause of painful red eye. This presentation however is far more typical of angle closure glaucoma.

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[accordion-item title=”Trigeminal Neuroalgia (click to show/hide)”]

Incorrect: Trigeminal neuralgia could cause a similar pain picture, but the eye signs and vision changes point to angle closure glaucoma as the most likely cause.

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Q4

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?

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[accordion-item title=”Discharge home with no follow up (click to show/hide)”]

Incorrect: Angle closure glaucoma is an ophthalmologic emergency. These patients need to see an ophthalmologist emergently.

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[accordion-item title=”Discharge home with follow up with Ophthalmology in one week (click to show/hide)”]

Incorrect: Angle closure glaucoma is an ophthalmologic emergency. These patients need to see an ophthalmologist emergently, not one week.

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[accordion-item title=”Emergent Ophthalmology consult (click to show/hide)”]

Correct: Ophthalmology should be consulted immediately for any patient with angle closure glaucoma.

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[accordion-item title=”Emergent Neurosurgery consult (click to show/hide)”]

Incorrect: Angle closure glaucoma is an ophthalmologic emergency. Consulting Neurosurgery is inappropriate in this case.

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[accordion-item title=”MRI of the brain (click to show/hide)”]

Incorrect: A MRI of the brain is not indicated for acute angle closure glaucoma. This patient needs an emergent Ophthalmology evaluation.

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Q5

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

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[accordion-item title=”IV mannitol (click to show/hide)”]

Correct: IV mannitol causes osmotic diuresis, thereby reducing the volume of vitreous humor, and decreasing IOP.

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[accordion-item title=”IV acetazolamide (click to show/hide)”]

Correct: IV acetazolamide decreases the production of aqueous humor and thus decreases IOP.

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[accordion-item title=”Tropical miotics (click to show/hide)”]

Correct: After IV mannitol and acetazolamide are administered, topical miotics may help withdraw the iris from the irido-corneal angle.

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[accordion-item title=”Needle aspiration of anterior chamber (click to show/hide)”]

Correct: The withdrawal of a small amount of fluid from the anterior chamber may help alleviate the increased IOP. This should only be done by an ophthalmologist.

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[accordion-item title=”Peripheral iridotomy (click to show/hide)”]

Correct: Peripheral iriotomy can be done either surgically, or with a YAG laser and will create a conduit between the anterior and posterior chambers of the eye.

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Summary

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.