Ophthalmology Series: Case 8

ANSWERS WILL BE POSTED AT 18:00 CET

A 42-year old lady presents to A&E with intense ocular pain on the left eye that started from the day before. She said she was losing her vision on her left eye (6/60) but her right was normal (6/6).  She mentioned that she would start seeing halos when she was in a well-lit room.
Over the last 24 hours, she reported that she was vomiting and wasn’t feel all too well.

1. What would be your differential diagnosis ? 

2. What is the most likely diagnosis ?

3. What would be the typical clinical examination findings ?

4. How would you investigate even further ?

5. Given the most likely diagnosis, how would you manage this patient acutely ? 

Image result for acute angle closure glaucoma fundoscopy


ANSWERS

1. Anterior Uveitis, Conjunctivitis,  Corneal abrasion, Corneal ulcer/foreign body, Endophthalmitis, Episcleritis and scleritis and an Inflamed Pterygium.

2. Acute angle closure glaucoma

3. Clinical Findings should include at least 3 of the following:

  • Intraocular pressure(IOP) greater than 21mmHg
  • Conjunctival Injection
  • Corneal epithelial oedema
  • Mild dilated non-reactive pupil
  • Shallower chamber in the presence of occlusion

4. Other investigations include:

  • Central corneal thickness measurement
  • Gonioscopy depth assessment of the iridocorneal angle and trabercular meshwork
  • Visual Field measurement using automated perimetry
  • Optic nerve assessment using steoscopic slit lamp with fundus examination.

5. Acute Management:

Recheck IOP at least hourly.Place patient in a supine position to reduce IOP in a well-lit room.

Primary Intervention drugs include:

  • topical beta blocker e.g. timolol
  • topical alpha blocker e.g. brimonidine ophthalmic
  • Acetazolamide PO

Facilitate outflow of aqueous humour by giving 1-2% Pilocarpine

Reduce volume of aqueous humour by giving 1-2 g/kg IV Mannitol 

Source: Rao, A., Padhy, D., Sarangi, S., & Das, G. (2016). Angle Closure Scoring System (ACSS)-A Scoring System for Stratification of Angle Closure Disease. PLoS ONE, 11(10), e0160209. http://doi.org/10.1371/journal.pone.0160209

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5 thoughts on “Ophthalmology Series: Case 8

  1. most likely diagnosis is acute closed angle glaucoma.Opthalmic emergency..need surgery laser iridotomy. other ddx: possible large vessel arteritis but less likely (get ESR), stroke/hemorraghe, or even pseudotumor cerebri (even though not woman, overweight childbearing age).

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