A 65-year-old Asian woman comes to the office because of a red right eye. She has severe pain in the eye and has developed decreased vision with halos around bright objects. Her symptoms started a few hours ago while attending a movie. She does not wear contact lenses and has had no purulent discharge from the eye. She denies a foreign body sensation in the eye and has not experienced any eye trauma. She had a recent upper respiratory tract infection for which she self-medicated with an over-the-counter medication.
Examination reveals a red right eye and a moderately dilated pupil with sluggish light reaction. There is pain with eye movement. Her vision is markedly reduced and she can count fingers at two feet.
Which of the following is the most likely cause of her symptoms?

Question

A 65-year-old Asian woman comes to the office because of a red right eye.  She has severe pain in the eye and has developed decreased vision with halos around bright objects.  Her symptoms started a few hours ago while attending a movie.  She does not wear contact lenses and has had no purulent discharge from the eye.  She denies a foreign body sensation in the eye and has not experienced any eye trauma.  She had a recent upper respiratory tract infection for which she self-medicated with an over-the-counter medication.
Examination reveals a red right eye and a moderately dilated pupil with sluggish light reaction.  There is pain with eye movement.  Her vision is markedly reduced and she can count fingers at two feet.
Which of the following is the most likely cause of her symptoms?

Quizplus · Accepted Answer

11ec193a_9897_de63_853d_d53b316588d2_MD0002_00 In the management of patients with acute eye problems, including the "red" eye, the main challenge is to determine when immediate referral to an ophthalmologist is appropriate. Patients need immediate evaluation or referral if they have impaired vision, inability to open the eye due to foreign body sensation, photophobia, significant eye pain, diminished pupil reactivity, and the presence of a corneal opacity. Acute angle-closure glaucoma is an ocular emergency and is most commonly seen in hyperopic older persons, especially in individuals of Asian ethnicity. Optic atrophy and vision loss can occur within hours without appropriate treatment. Patients are often slumped over in distress while covering the affected eye and complain of headache, nausea, and vomiting. Examination shows a fixed pupil in mid-dilation, a red eye, ciliary flush, elevated ocular pressures, and no discharge. Acute angle-closure glaucoma can be precipitated by exposure to sympathomimetic and anticholinergic drugs. (Choice B) Acute anterior uveitis usually affects younger individuals and requires urgent ophthalmologic referral. It is usually associated with a red eye, pain, decreased vision, white or yellowish discharge at the base of the anterior chamber, and a normal pupil response. (Choice C) Bacterial conjunctivitis is usually associated with significant purulent discharge, often with swelling of the lid and a markedly inflamed red eye. There may be some mild pain, but the pupils react normally with normal vision. (Choice D) Complicated corneal abrasion is often associated with contact lens use or trauma and presents with a painful red eye, slightly diminished vision, and normal pupillary response. (Choice E) Temporal arteritis can present with headache and acute vision loss, but the eye is usually not red and the patient often has symptoms of polymyalgia rheumatica. Educational objective: A red eye associated with significant pain, visual loss, vomiting, headache, and abnormal pupil reactivity in an older individual is diagnostic of acute angle-closure glaucoma. Immediate referral to ophthalmology is required for treatment in order to prevent irreversible optic nerve damage. __________ References: Angle-closure glaucoma: the role of the lens in the pathogenesis, prevention, and treatment (http://www.ncbi.nlm.nih.gov/pubmed/19298900) The acute painful eye (http://www.ncbi.nlm.nih.gov/pubmed/3278885)

A 65-Year-Old Asian Woman Comes to the Office Because of a Red