A 60-year-old woman comes to the emergency department due to a sudden onset of severe pain in her left eye with blurred vision, nausea, and vomiting. The symptoms began a few minutes ago, while she was watching a movie in a nearby theater. Her temperature is 36.8C (98.4F), blood pressure is 140/90 mm Hg, pulse is 82/min, and respirations are 14/min. Examination reveals decreased visual acuity. Her left eye appears red, with a hazy cornea, shallow anterior chamber, and dilated, fixed pupil. Her left eye is stony hard to touch. What is the most likely diagnosis?

Question

A 60-year-old woman comes to the emergency department due to a sudden onset of severe pain in her left eye with blurred vision, nausea, and vomiting.  The symptoms began a few minutes ago, while she was watching a movie in a nearby theater.  Her temperature is 36.8C (98.4F), blood pressure is 140/90 mm Hg, pulse is 82/min, and respirations are 14/min.  Examination reveals decreased visual acuity.  Her left eye appears red, with a hazy cornea, shallow anterior chamber, and dilated, fixed pupil.  Her left eye is stony hard to touch.  What is the most likely diagnosis?

Quizplus · Accepted Answer

Angle closure glaucoma occurs with closure of a pre-existing narrow anterior chamber angle. It predominantly occurs in people aged 55-70 years. It presents with an acute onset of severe eye pain and blurred vision associated with nausea and vomiting. It usually occurs following pupillary dilation, which may occur in darkened movie theaters, during times of stress, or due to drug intake. Examination reveals a red eye with steamy cornea and moderately dilated pupil that is non reactive to light. The anterior chamber is shallow with inflammatory changes. Tonometry reveals increased intraocular pressure. Intravenous acetazolamide (with subsequent oral administration) may lower the intraocular pressure. Permanent cure is offered with laser peripheral iridotomy. (Choice A) Open angle glaucoma has an insidious onset, with gradual loss of peripheral vision resulting in tunnel vision. Other characteristic features are persistently increased intraocular pressure and pathologic cupping of the optic disc. (Choice B) Conjunctivitis is characterized by very mild pain. The cornea is clear. Pupillary size and response to light is normal. Visual acuity is not affected. (Choice D) Uveitis presents with moderate pain and blurred vision. Cornea may be hazy. The anterior chamber shows flare and cells on slit lamp examination. The pupil is constricted with a poor light response (In acute glaucoma, the pupil is dilated and is nonreactive to light). (Choice E) Corneal abrasion presents with severe pain and photophobia. There is usually a history of trauma to the eye. Slit lamp examination with fluorescein will reveal the corneal abrasion. Educational objective: Angle closure glaucoma occurs predominantly in people aged 55-70 years. It presents with an acute onset of severe eye pain and blurred vision associated with nausea and vomiting. Examination reveals a red eye with steamy cornea and moderately dilated pupil that is non reactive to light.

A 60-Year-Old Woman Comes to the Emergency Department Due to a Sudden