A 62-year-old man comes to the office due to sudden onset of pain and redness in the left eye. The patient also has photophobia, nausea, and a severe headache that has not responded to ibuprofen. There has been no trauma, and he has never had such an episode before. Medical history is unremarkable. On review of systems, the patient has had "a mild cold" for which he has been using an over-the-counter oral decongestant. Physical examination shows a nonreactive, mid-dilated left pupil. The eye appears red with conjunctival flushing. Which of the following is the best next step in evaluating this patient's condition?

Question

A 62-year-old man comes to the office due to sudden onset of pain and redness in the left eye.  The patient also has photophobia, nausea, and a severe headache that has not responded to ibuprofen.  There has been no trauma, and he has never had such an episode before.  Medical history is unremarkable.  On review of systems, the patient has had "a mild cold" for which he has been using an over-the-counter oral decongestant.  Physical examination shows a nonreactive, mid-dilated left pupil.  The eye appears red with conjunctival flushing.  Which of the following is the best next step in evaluating this patient's condition?

Quizplus · Accepted Answer

11ec25c8_d29b_b825_bc81_59298853d6bb_MD0003_00 This patient with headache, nausea, eye pain, and a nonreactive mid-dilated pupil has typical features of acute angle-closure glaucoma (ACG), possibly precipitated by decongestant use. ACG is characterized by an acute rise in intraocular pressure (IOP) due to impaired drainage of aqueous humor through the anterior chamber to the trabecular meshwork at the iridocorneal angle. This increased IOP can damage the optic nerve and lead to permanent vision loss. drainage of aqueous humor ACG can be triggered by pupillary dilation (eg, low ambient light) or certain medications (eg, decongestants, anticholinergic drugs) in patients with predisposing anatomy. Symptoms include acute eye pain, headache, nausea, diminished vision, and halos around lights. Examination shows a nonreactive and mid-dilated pupil, conjunctival redness, and corneal opacification. Urgent ophthalmologic consultation is indicated in suspected ACG. The gold standard for diagnosis is gonioscopy, which uses a specialized prismatic lens with a slit lamp to visualize the iridocorneal angle. An ocular tonometer measures IOP and can provide additional information if ophthalmologic consultation is not available immediately. The device is placed against the cornea, quantitated pressure is applied, and the resulting indentation is measured. Initial ACG management includes intravenous acetazolamide and pressure-lowering eye drops; laser iridotomy provides definitive care. (Choice A) Urgent noncontrast CT scan of the head is indicated for suspected intracranial hemorrhage (eg, sudden-onset severe headache, altered mental status). A CT scan is also useful to assess for an intracranial mass in patients with focal neurologic deficits. However, this patient's ocular findings are more consistent with ACG. (Choice B) Duplex studies of the carotid arteries are done to evaluate the carotid artery for plaques or stenosis. Emboli released from carotid plaques can cause retinal artery occlusion with sudden vision loss, but this is typically painless and does not normally cause conjunctival redness. (Choice C) Fluorescein staining of the eye is usually performed to detect corneal abrasions or herpetic keratitis. Headache, nausea, and a mid-dilated pupil are not typical in these conditions and are more consistent with ACG. (Choice D) Lumbar puncture is useful to assess for subarachnoid hemorrhage (eg, thunderclap headache, meningeal signs) or meningitis (eg, fever, neck stiffness). Headache is common with these conditions, but a unilateral red eye with mid-dilated pupil is more consistent with ACG. Educational objective: Acute angle-closure glaucoma is characterized by acute eye pain, headache, and nausea. Signs include conjunctival erythema, corneal opacification, and a mid-dilated pupil. Gonioscopy is the gold standard for diagnosis. Ocular tonometry can be helpful if urgent ophthalmologic consultation is unavailable. References: Iatrogenic glaucoma secondary to medications. (http://www.ncbi.nlm.nih.gov/pubmed/21092926)

A 62-Year-Old Man Comes to the Office Due to Sudden