Acute Angle Closure Glaucoma
+ Painful, Unilateral vision loss
+ Headache +Nausea/Vomiting
No foreign body sensation, no FB on exam.
No recent eye trauma or suspected microtrauma (dust, sand, etc).
Negative Seidel sign.
No significant photophobia.
IOP (> 22 in affected eye)
Visual Acuity: Reduced from baseline.
Presentation most consistent with Acute Angle Glaucoma.
Given PAINFUL vision loss I also considered Corneal Abrasion/Ulcer, Complex Migraine, Globe Rupture, Uveitis, Endopthalmitis, Orbital and Periorbital Cellulitis, Optic Neuritis.
Consult: Opthalmology; query steroid use
ED Interventions:
Timolol 0.5% (1 drop in affected eye)
Pilocarpine 1 drop in affected eye q15 minutes x 2
Acetazolamide 500mg PO with consult
Analgesia and Antiemetics PRN
Supine positioning in lighted room with hourly IOP checks
- Background
- MOA: “Closed Angle” –> backup of fluid –> “Intra-Orbital Compartment Syndrome” = damage to optic nerve.
- Risk factors: older age (larger lenses), females (shallower anterior chamber), Asian descent (narrower angles at baseline), more likely to occur in patients without a history of chronic glaucoma.
- Treatment
- Avoid patching or covering eye: may increase pressure, also promotes pupillary dilation
- Goals: Decrease IOP, Decrease inflammation, Reverse angle closure
- **Acetazolamide: (IV or PO) Carbonic anhydrase inhibitor, decreases aqueous humor production (contraindicated if sulfa allergy or sickle cell disease)
- **Timolol: (topical) Beta blocker, decreases aqueous humor production
- **Prednisolone: (topical) steroid, reduces inflammation
- Pilocarpine: (topical), causes miosis/constriction of pupil and increase drainage from the anterior chamber
- should be given approx 1hr after initial meds (initial increased IOP causes pressure-induced ischemic paralysis so likely does not work until IOP drops below 40-50 mmHg, but still give immediately upon diagnosis
- Apraclonidine or Brimonidine: (topical) alpha-agonist, reduces aqueous humor production, consider for additional IOP reduction
- Osmotic agents such as glycerol, isosorbide (diabetics) or mannitol cause diuresis
- indicated for persistent increased IOP after 2 doses of pilocarpine
- Treat pain and nausea as both may increase IOP
Optic Neuritis
Pertinent Negatives: No recent fever, sinus pressure, rhinorrhea, neck trauma or rapid neck rotational force, floaters, field cut. No neurologic deficits consistent with stroke.
Given PAINFUL vision loss I also considered Corneal Abrasion/Ulcer, Complex Migraine, Globe Rupture, Uveitis, Endopthalmitis, Orbital and Periorbital Cellulitis, Acute angle closure glaucoma.
Workup: Labs and MRI brain and orbits [with gadolinium, plus fat suppression]
- Labs
- CBC, CMP, ESR, CRP, RPR, FTABS
- (Consult with neuro regarding CSF and serum studies):
- Typically protein/glucose, gram stain/culture, cell count/differential
- Plus angioconverting enzyme, IgG indices, myelin basic protein, oligoclonal bands
- Plus SERUM IgG indices, oligoclonal bands, angioconverting enzyme, NMO antibodies
- Imaging
- Leif MRI nondiagnostic: to rule out neuromyelitis optica
Anterior Uveitis
+ Photophobia
+ Decreased Visual Acuity in affected eye
+ Cells on slit-lamp exam of anterior chamber
Presentation most consistent with Anterior Uveitis.
Given PAINFUL vision loss I also considered but believe presentation less likely consistent with Corneal Abrasion/Ulcer, Complex Migraine, Globe Rupture, Glaucoma, Endopthalmitis, Orbital and Periorbital Cellulitis, Optic Neuritis.
Rx: Tropicamide 1% q.i.d.
Disposition: Follow up with Ophthalmology in 24-48 hours.
- MOA: Autoimmune response
- can be isolated or develop in association with seronegative spondyloarthropathies (herpes simplex, herpes zoster, sarcoidosis, Bechet disease)
- Tx:
- Cycloplegics: (cyclopentolate 1% t.i.d., tropicamide 1% q.i.d.)
- Prednisolone acetate 1% drops q6h for mild disease (in consultation with Ophthalmology)
- https://eyewiki.aao.org/Treatment_of_Uveitis
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