68 y.o. F with pain in right eye

1. 68 y.o. F with pain in right eye Christopher Wang, MSIV Albert Einstein College of Medicine Jacobi/Monte EM Elective 6/22/12

2. Case • 68 y.o. F w/ PMH of HTN, “chronic dry corneas,” sent from clinic with right eye pain and headache • MR: 02974022

3. 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

4. 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

5. 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

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

7. 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

8. 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

9. ROS • + Nausea, no vomiting • No fever or chills • No abdominal pain • No diaphoresis • No recent sick contacts

10. ROS cont’d • + Lacrimation, no crusting • No photophobia • Able to keep eye open • No sensation of foreign body in eye • No contact lens use

11. During Exam • Pt begins to vomit

12. Differential Diagnosis • Acute angle-closure glaucoma • Keratitis • Ophthalmic herpes • Iritis/Uveitis • Conjunctivitis • Infective vs. Allergic • Subconjunctival hemorrhage

13. Anatomy

14. 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)

15. Acute Angle-Closure Glaucoma

16. 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

17. Keratitis

18. 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

19. Herpetic Infection

20. Iritis/Uveitis • Caused by infection, autoimmune disorders, meds • Sx: pain, decreased visual acuity, photophobia • Eye exam: circumcorneal injection, constricted pupils • Dx: slit lamp

21. Iritis/Uveitis

22. 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

23. Infective Conjunctivitis

24. 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

25. Allergic Conjunctivitis

26. 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

27. Subconjunctival Hemorrhage

28. Differential Diagnosis • Acute angle-closure glaucoma • Keratitis • Ophthalmic herpes • Iritis/Uveitis • Conjunctivitis • Infective vs. Allergic • Subconjunctival hemorrhage

29. Top of the Differential • Acute angle-closure glaucoma (AACG)

30. Acute Angle-Closure Glaucoma

31. Acute Angle-Closure Glaucoma

32. 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

33. Workup for AACG • Intraocular pressure of both eyes measured with Tonopen • R eye: 60mm Hg L eye: 15mm Hg • Normal: 8 – 21mm Hg

34. 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!

35. 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

36. Definitive Treatment for AACG • Pt seen at 9:30am in Ophtho Clinic for peripheral iridotomy

37. 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