68 y.o. F with pain in right eye

Christopher Wang, MSIVAlbert Einstein College of MedicineJacobi/Monte EM Elective6/22/12

Case

68 y.o. F w/ PMH of HTN, “chronic dry corneas,” sent from clinic with right eye pain and headache

MR: 02974022

Case

R eye pain began on 5/30 @ 6:00pm Described as 8/10 “pressure”

No recent trauma Pain followed by R-sided frontal HA Pain increased gradually over time Vision increasingly blurry

Case

Pt sought medical help at primary care clinic on morning of 5/31, told to go to ED

Went home for several hours Came to Monte ED in afternoon Pt seen at 5:30pm

Case

PMH: osteopenia, arthritis (hip), HTN, chronic “dry corneas”

PSH: none FH: DM, asthma Social: smoked cig. “years ago”

EtOH 1-2 drinks/month

no drugs

no sexual activity for several years

unemployed, lives with son Meds: Lisinopril, Diclofenac eye drops

Vitals

T: 97.0F P: 64 R: 20 BP: 182/84 O2 sat: 98% on RA

Exam

Pleasant woman in NAD EOMI, movement painless Left eye visual acuity: 20/20 Right eye visual acuity: 20/100 Diminished right sided peripheral vision Lacrimation from right eye

Exam

Right eye: Diffuse conjunctival injection Pupil dilated 5mm, fixed, non-reactive Corneal edema/clouding Globe hard upon palpation No hyphema or hypopyon Fundus not visualized

Left eye: WNL

ROS

+ Nausea, no vomiting No fever or chills No abdominal pain No diaphoresis No recent sick contacts

ROS cont’d

+ Lacrimation, no crusting No photophobia Able to keep eye open No sensation of foreign body in eye No contact lens use

During Exam

Pt begins to vomit

Differential Diagnosis

Acute angle-closure glaucoma Keratitis Ophthalmic herpes Iritis/Uveitis Conjunctivitis

Infective vs. Allergic Subconjunctival hemorrhage

Anatomy

Acute Angle-Closure Glaucoma

Due to sudden narrowing or closure of anterior chamber angle where aqueous humor drains

Sx: pain, decreased visual acuity, photophobia, HA, N/V

Eye exam: diffuse injection, cloudy cornea, fixed dilated nonreactive pupil

Dx: elevated intraocular pressure (IOP)

Acute Angle-Closure Glaucoma

Keratitis

Corneal inflammation due to trauma, infxn Assoc. with contact lenses Sx: pain, decreased visual acuity,

photophobia, inability to keep eye open Eye exam: diffuse injection, abrasion,

ulceration, or foreign body in cornea, hypopyon

Dx: fluorescein staining

Keratitis

Herpetic Infection

Infection w/ HSV-1 of trigeminal ganglion Sx: mimics keratitis – pain, decreased

visual acuity, photophobia, Hutchinson’s sign

Eye exam: diffuse injection, decreased corneal sensation

Dx: fluorescein staining – dendritic lesion

Herpetic Infection

Iritis/Uveitis

Caused by infection, autoimmune disorders, meds

Sx: pain, decreased visual acuity, photophobia

Eye exam: circumcorneal injection, constricted pupils

Dx: slit lamp

Iritis/Uveitis

Infective Conjunctivitis

Due to bacterial or viral infxn Sx: no pain, no change in vision, no

photophobia, but purulent discharge Eye exam: diffuse injection, chemosis,

lid involvement Dx: clinical, abx, self-limited

Infective Conjunctivitis

Allergic Conjunctivitis

Allergic rxn to airborne allergens, drugs, cosmetics, contact lens products

Sx: no pain, no change in vision, no photophobia, but purulent discharge and pruritus

Eye exam: diffuse injection, lid involvement, chemosis, cobblestoning under eye lids

Dx: clinical

Allergic Conjunctivitis

Subconjunctival Hemorrhage

Extravasated blood below surface of conjunctiva

Due to valsalva from coughing, sneezing, straining, vomiting

Sx: none Eye exam: clearly demarcated

extravasated blood in conjunctiva

Subconjunctival Hemorrhage

Differential Diagnosis

Acute angle-closure glaucoma Keratitis Ophthalmic herpes Iritis/Uveitis Conjunctivitis

Infective vs. Allergic Subconjunctival hemorrhage

Top of the Differential

Acute angle-closure glaucoma (AACG)

Acute Angle-Closure Glaucoma

Acute Angle-Closure Glaucoma

Workup for AACG

Suspected AACG = Emergency! Rapidly increasing intraocular pressure

leads to optic nerve damage blindness Requires treatment w/in 24 hours of

symptom onset Ophtho consulted immediately

Workup for AACG

Intraocular pressure of both eyes measured with Tonopen

R eye: 60mm Hg L eye: 15mm Hg Normal: 8 – 21mm Hg

Treatment for AACG

Pt given Zofran, Naprosyn, Percocet

Pt started on eye drops @ 6:27pm: Timolol 0.5% 1gtt OD Q15min Brimonidine tartrate 0.2% 1gtt OD Q15min Dorzolamide HCl 0.2% 1gtt OD Q15min Latanoprost 0.005 g 1gtt OD Q15min

Diamox 250mg IVP @ 7:00pm + 8:45pm

No change in IOP!

Treatment for AACG

Mannitol 77g IV over 45min @ 10:30pm Pilocarpine 1% 1gtt OD @ 11:45pm

R eye IOP = 25mm Hg Pt discharged to home @ 4:45am on 6/1

Definitive Treatment for AACG

Pt seen at 9:30am in Ophtho Clinic for peripheral iridotomy

The End

Hamilton, Sanders, Strange, et al. Emergency Medicine: An Approach to Clinical Problem Solving. 1st ed. Philadelphia, PA: W.B. Saunders; 1991: 575-594

Jacobs, Trobe, Sokol. Evaluation of the red eye. Up-to-Date; http://www.uptodate.com/contents/evaluation-of-the-red-eye; 9/21/11

Toy, Simon, Takenaka, et al. Case Files: Emergency Medicine. 2nd ed. United States: McGraw Hill; 2009

Weizer, Trobe, Sokol. Angle-Closure Glaucoma. Up-to-Date; http://www.uptodate.com/contents/angle-closure-glaucoma; 1/18/12