Ophthalmology KFP 1.4 – Feng has a painful eye

by | Jan 13, 2018

Feng is a 55 year old woman of Chinese descent, with a history of myopia, who presents to your country practice with severe left eye pain, red eye, nausea and vomiting which started last night while he was watching an emotional TV show in the dark. Shee now can barely see her hand in front of her face and state that lights have rainbow haloes around them.

What is the most likely diagnosis for this presentation? (1)

  1. Acute Angle Closure Glaucoma

What are the differentials for this presentation? (6)

  1. Iritis
  2. Keratitis
  3. Herpes zoster Ophthalmicus
  4. Scleritis
  5. Optic neuritis
  6. Corneal disorder
  7. Endophthalmitis
  8. Anterior uveitis
  9. Corneal abrasion
  10. Conjunctivitis
  11. Foreign body
  12. Conjunctival hemorrhage

What are the KEY FEATURES OF HISTORY in acute angle closure glaucoma? (6)

  1. Severe ocular pain
  2. Frontal headache
  3. Vomiting
  4. Nausea
  5. Eye redness
  6. Blurring of vision
  7. Visual loss
  8. Coloured halos around lights

What are the KEY FEATURES OF EXAMINATION in acute angle closure glaucoma? (6)

  1. Patient generally unwell with intense eye pain
  2. Injected conjunctivae / red eye
  3. VA decreased
  4. Visual field loss
  5. Eye is rock hard to palpation
  6. IOP typically severely elevated > 50
  7. fixed semidilated pupil
  8. Non-reacting pupil
  9. Very high IOP
  10. Cloudy cornea
  11. Swollen cornea
  12. Shallow anterior chamber
  13. Pronounced cupping
  14. Pale central depression of optic disc
  15. Increased cup to disc ratio of > 0.6

What is a normal intraocular pressure? (1)

  1. 10-20 mmHg

What are the MOST IMPORTANT IMMEDATE MANAGEMENT steps in managing acute angle closure glaucoma? (3)

  1. Immediate referral to ophthalmologist
  2. IV or PO Acetazolamide 500mg
  3. Check IOP hourly

What are the risk factors for the primary form of acute angle closure glaucoma?

  1. shallow anterior chamber
  2. female
  3. age
  4. Asian ethnicity
  5. long sightedness (hyperopia)
  6. family history
  7. previous history

What are the secondary causes of acute angle closure glaucoma? (5)

  1. Anterior Uveitis
  2. Neovascular glaucom
  3. membranous obstruction, e.g. iridocorneal endothelial syndrome
  4. lens-induced, e.g. large lens or small eye
  5. drugs, e.g. topiramate and sulfonamides, SSRIs
  6. central retinal vein occlusion (CRVO)
  7. post-op/ laser treatment
  8. posterior segment tumour
  9. cataracts
  10. eye injuries
  11. SSRIs
  12. Dark room

Which classes of medications can precipitate acute angle closure glaucoma? (4)

  1. Topical vasodilators
  2. SSRIs
  3. Topimarate
  4. Sulfonamides

What medication should not be given if the IOP is > 40mmHg in acute angle closure glaucoma?

  1. Topical pilocarpine

What are the main categories/classes of medications used to treat acute angle closure glaucoma? (5)

  1. Beta blockers
  2. Postaglandin derivatives
  3. Alpha 2 adreneric agents
  4. Miotics
  5. Carbonic anhydrase inhibitors

What are the complications that can arise from acute angle closure glaucoma? (2)

  1. permanent loss of vision,
  2. repetition of the acute attack,
  3. attack in the fellow eye
  4. central retinal artery or vein occlusion.

Acute Angle Closure Glaucoma on Soundcloud

References

https://patient.info/doctor/primary-open-angle-glaucoma

http://www.racgp.org.au/afp/2014/july/eye-care-in-the-elderly/

http://www.australiandoctor.com.au/cmspages/getfile.aspx?guid=50b1dafb-83c8-4f2b-9006-2030c44c7cab

https://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp113_b_glaucoma_guide_healthcare_workers.pdf?

http://www.graduatemedicine.com/kb/a/1630/c/15722/acute-glaucoma

http://www.racgp.org.au/your-practice/guidelines/redbook/12-glaucoma/