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 ?
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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