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:

3. Case R eye pain began on 5/30 @ 6:00pm No recent trauma
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
Diclofenac – COX-1,2 reversible inhibitor – can be used as eye drop for postoperative inflammation from cataract extraction, relief of pain and photophobia in pts undergoing corneal refractive surgery. Adverse effects: keratitis, corneal perforation

6. Vitals T: 97.0F P: 64 R: 20 BP: 182/84 O2 sat: 98% on RA
Point out HTN – due to her HTN, stress, not due to increased cerebral pressure – no global pressure

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: Left eye: WNL 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
Corneal edema: clouding of the cornea – difficult to do fundoscopy
Hyphema: blood in anterior chamber of eye – due to trauma
Hypopyon: leukocytic exudate in anterior chamber of eye – sign of inflammation of anterior uvea and iris - uveitis

9. ROS + Nausea, no vomiting No fever or chills No abdominal pain
No diaphoresis
No recent sick contacts
Acute angle-closure glaucoma – nausea, vomiting, abdominal pain, diaphoresis, frontal headache

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
Morning crust = allergy, stye, viral conjunctivitis, allergic conjunctivitis, dry eyes
Crusting throughout the day = bacterial conjunctivitis, bacterial keratitis
Inability to keep eye open – objective sign = corneal involvement
Photophobia – corneal or iris involvement
Corneal process = photophobia + objective signs of foreign body
Uveitis = photophobia + NO OBJECTIVE signs of foreign body
Sensation of foreign body in eye – subjective sign, feels scratchy, gritty, sand in eyes = allergy, viral conjunctivitis, dry eyes
Contact lens use = keratitis

11. During Exam
Pt begins to vomit
WHAT IS YOUR DIFFERENTIAL?

12. Differential Diagnosis
Acute angle-closure glaucoma
Keratitis
Ophthalmic herpes
Iritis/Uveitis
Conjunctivitis
Infective vs. Allergic
Subconjunctival hemorrhage
Acute angle-closure glaucoma –
For: HA, N/V, pain, decreased visual acuity, no discharge, diffuse conjunctival injection, cloudy cornea, fixed, dilated, pupil, hard globe.
Against: no photophobia in this pt, which is typical of glaucoma.
Keratitis – cornea has well-developed sensory fibers, trauma/infection/inflammation assoc. w/ pain, objective foreign body sensation – inability to keep eye open
For: pain, decreased visual acuity, diffuse conjunctival injection.
Against: no photophobia, no discharge, no abrasion, ulceration, or foreign body in cornea grossly visualized (would require fluoroscein examination), pupils are not normal in size and response, globe is hard, no objective signs of corneal involvement – she is able to keep eye open
Iritis, uveitis – iris and ciliary body have same blood supply, so often involved together = called uveitis. Vision blurred due to cells and protein in aqueous humor, causes photophobia due to ciliary body spasm. Pupils constrict due to iris involvement.
For: pain, decreased visual acuity, no discharge.
Against: no photophobia, diffuse injection rather than circumcorneal, cornea is cloudy not clear, pupils are dilated not constricted, globe is hard rather than normal
Conjunctivitis – characterized by vasodilation, fluid exudation (swelling), cellular migration (discharge)
For: no photophobia, diffuse injection (although often involves lid).
Against: pain is severe (usually non-existent in conjunctivitis), decreased visual acuity, no discharge, cornea is cloudy not clear, pupils are dilated not normal, globe is hard rather than normal

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)
For: HA, N/V, pain, decreased visual acuity, no discharge, diffuse conjunctival injection, cloudy cornea, fixed, dilated, pupil, hard globe.
Against: no photophobia in this pt, which is typical of glaucoma.

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
Keratitis – cornea has well-developed sensory fibers, trauma/infection/inflammation assoc. w/ pain, objective foreign body sensation – inability to keep eye open, scattering of light leads to photophobia, abrasions lead to decreased vision
For: pain, decreased visual acuity, diffuse conjunctival injection.
Against: no photophobia, no discharge, no abrasion, ulceration, or foreign body in cornea grossly visualized (would require fluoroscein examination), pupils are not normal in size and response, globe is hard, no objective signs of corneal involvement – she is able to keep eye open
Dx: fluorescein staining shows corenal abrasion or foreign body

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
Hutchinson’s sign: skin lesion on tip of nose, precedes development of ophthlamic herpes, due to nasocilliary branch of trigeminal nerve serving both the cornea and the tip of the nose
Tx: topical antiviral agents (vidarabine, trifluridine,acyclovir, and ganciclovir)

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
Iritis, uveitis – iris and ciliary body have same blood supply, so often involved together = called uveitis. Vision blurred due to cells and protein in aqueous humor, causes photophobia due to ciliary body spasm. Pupils constrict due to iris involvement.
For: pain, decreased visual acuity, no discharge.
Against: no photophobia, diffuse injection rather than circumcorneal, cornea is cloudy not clear, pupils are dilated not constricted, globe is hard rather than normal
Sx: slit lamp to look for cells and protein exudation in anterior chamber

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
Purulent discharge w/ crusting of lid margin  bacterial infection>viral
Chemosis = swelling/edema of conjunctiva
Exception to pain rule: Gonorrhea!
If unresponsive to antibiotics, recurrent, young sexually active pt  Chlamydia

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
Chemosis = swelling/edema of conjunctiva
Often binocular, but can be uniocular if flying insects lodge in conjunctiva.
Vernal conjunctivitis – spring and fall, cobblestone papillae under eye lid, thick yellow discharge

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
Blood resorbs w/in 1-2 weeks
But if associated w/ trauma, evaluate for ruptured globe or retrobulbar hemorrhage

27. Subconjunctival Hemorrhage

28. Differential Diagnosis
Acute angle-closure glaucoma
Keratitis
Ophthalmic herpes
Iritis/Uveitis
Conjunctivitis
Infective vs. Allergic
Subconjunctival hemorrhage
Acute angle-closure glaucoma –
For: HA, N/V, pain, decreased visual acuity, no discharge, diffuse conjunctival injection, cloudy cornea, fixed, dilated, pupil, hard globe.
Against: no photophobia in this pt, which is typical of glaucoma.
Keratitis – cornea has well-developed sensory fibers, trauma/infection/inflammation assoc. w/ pain, objective foreign body sensation – inability to keep eye open
For: pain, decreased visual acuity, diffuse conjunctival injection.
Against: no photophobia, no discharge, no abrasion, ulceration, or foreign body in cornea grossly visualized (would require fluoroscein examination), pupils are not normal in size and response, globe is hard, no objective signs of corneal involvement – she is able to keep eye open
Iritis, uveitis – iris and ciliary body have same blood supply, so often involved together = called uveitis. Vision blurred due to cells and protein in aqueous humor, causes photophobia due to ciliary body spasm. Pupils constrict due to iris involvement.
For: pain, decreased visual acuity, no discharge.
Against: no photophobia, diffuse injection rather than circumcorneal, cornea is cloudy not clear, pupils are dilated not constricted, globe is hard rather than normal
Conjunctivitis – characterized by vasodilation, fluid exudation (swelling), cellular migration (discharge)
For: no photophobia, diffuse injection (although often involves lid).
Against: pain is severe (usually non-existent in conjunctivitis), decreased visual acuity, no discharge, cornea is cloudy not clear, pupils are dilated not normal, globe is hard rather than normal

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 6:27pm:
Timolol 0.5% 1gtt OD Q15min
Brimonidine tartrate 0.2% 1gtt OD Q15min
Dorzolamide HCl 0.2% 1gtt OD Q15min
Latanoprost g 1gtt OD Q15min
Diamox 250mg 7:00pm + 8:45pm
No change in IOP!
Timolol – B1 and B2 blocker, reduces aqueous humor production or inflow
Brimonidine – A2 agonist, reduces aqueous humor production and increases uveoscleral outflow (secondary drainage), reduces sympathetic tone
Dorzolamide – Carbonic anhydrase inhibitor, decreases production of aqueous humor
Latanoprost - prostaglandin F2-alpha analog believed to reduce intraocular pressure by increasing the outflow of the aqueous humor
Diamox: acetazolamide = carbonic anhydrase inhibitor resulting in reduction of hydrogen ion secretion at renal tubule and an increased renal excretion of sodium, potassium, bicarbonate, and water. Decreases production of aqueous humor and inhibits carbonic anhydrase in central nervous system to retard abnormal and excessive discharge from CNS neurons
Beware topical Beta blockers in pts w/ Asthma, COPD, Bradycardia, Heart block, CHF, Myasthenia gravis
Reduce systemic absorption of topical agents by 70% by telling pt to close eyes while occluding lower tear ducts at the root of the nose after applying drops

35. Treatment for AACG Mannitol 77g IV over 45min @ 10:30pm
Pilocarpine 1% 1gtt 11:45pm
R eye IOP = 25mm Hg
Pt discharged to 4:45am on 6/1
Mannitol: osmotic agent used to dehydrate vitreous humor – beware in hypotensive pts with poor cardiac function
Pilocarpine: stimulates cholinergic receptors in the eye causing miosis via contraction of iris sphincter  decreases resistance of aqueous humor outflow
Peripheral iridotomy – definitive treatment - creates a tiny hole in the peripheral iris through which aqueous humor can flow and reach the angle [15]. Once the iridotomy is patent, pupillary block is bypassed. Peripheral iridotomy is usually created with a laser.

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:
Jacobs, Trobe, Sokol. Evaluation of the red eye. Up-to-Date; 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; 1/18/12