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68 y.o. F with pain in right eye
Christopher Wang, MSIVAlbert Einstein College of MedicineJacobi/Monte EM Elective6/22/12
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Case
68 y.o. F w/ PMH of HTN, “chronic dry corneas,” sent from clinic with right eye pain and headache
MR: 02974022
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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
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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
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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
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Vitals
T: 97.0F P: 64 R: 20 BP: 182/84 O2 sat: 98% on RA
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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
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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
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ROS
+ Nausea, no vomiting No fever or chills No abdominal pain No diaphoresis No recent sick contacts
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ROS cont’d
+ Lacrimation, no crusting No photophobia Able to keep eye open No sensation of foreign body in eye No contact lens use
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During Exam
Pt begins to vomit
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Differential Diagnosis
Acute angle-closure glaucoma Keratitis Ophthalmic herpes Iritis/Uveitis Conjunctivitis
Infective vs. Allergic Subconjunctival hemorrhage
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Anatomy
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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)
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Acute Angle-Closure Glaucoma
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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
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Keratitis
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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
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Herpetic Infection
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Iritis/Uveitis
Caused by infection, autoimmune disorders, meds
Sx: pain, decreased visual acuity, photophobia
Eye exam: circumcorneal injection, constricted pupils
Dx: slit lamp
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Iritis/Uveitis
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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
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Infective Conjunctivitis
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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
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Allergic Conjunctivitis
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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
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Subconjunctival Hemorrhage
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Differential Diagnosis
Acute angle-closure glaucoma Keratitis Ophthalmic herpes Iritis/Uveitis Conjunctivitis
Infective vs. Allergic Subconjunctival hemorrhage
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Top of the Differential
Acute angle-closure glaucoma (AACG)
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Acute Angle-Closure Glaucoma
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Acute Angle-Closure Glaucoma
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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
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Workup for AACG
Intraocular pressure of both eyes measured with Tonopen
R eye: 60mm Hg L eye: 15mm Hg Normal: 8 – 21mm Hg
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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!
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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
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Definitive Treatment for AACG
Pt seen at 9:30am in Ophtho Clinic for peripheral iridotomy
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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