A 62-year-old woman is brought to the emergency department due to an acute right-sided headache, ocular pain, and nausea. She was watching television in the evening after dinner when the symptoms began; initial treatment with cold compresses and acetaminophen was ineffective. The patient then developed decreased vision in the right eye and called for an ambulance. On examination, she appears uncomfortable and has episodic retching. The right eye has red conjunctival flushing; the right pupil is mid-dilated and nonreactive to light. Which of the following is the most appropriate next step in management of this patient?

Question

A 62-year-old woman is brought to the emergency department due to an acute right-sided headache, ocular pain, and nausea.  She was watching television in the evening after dinner when the symptoms began; initial treatment with cold compresses and acetaminophen was ineffective.  The patient then developed decreased vision in the right eye and called for an ambulance.  On examination, she appears uncomfortable and has episodic retching.  The right eye has red conjunctival flushing; the right pupil is mid-dilated and nonreactive to light.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d84f_870f_bc81_0110194f4510_MD0003_00 This patient has acute angle-closure glaucoma (ACG) presenting with headache, ocular pain, nausea, and decreased visual acuity. ACG is characterized by narrowing or closure of the anterior chamber angle, leading to decreased aqueous outflow and elevated intraocular pressure (IOP). Examination findings include conjunctival injection; corneal edema; palpable firmness of the eyeball; and a fixed, mid-dilated pupil. The diagnosis is confirmed by gonioscopy to visualize the corneal angle and/or tonometry to measure IOP. decreased aqueous outflow Initial management is directed at rapidly lowering IOP. Combination therapy with multiple topical agents is recommended; a typical regimen includes timolol (which reduces aqueous production), apraclonidine (which decreases aqueous production and increases outflow), and pilocarpine (which causes ciliary muscle contraction to open the trabecular meshwork at the corneal angle) eye drops. In addition, oral or intravenous acetazolamide is recommended to rapidly reduce further production of aqueous humor. Subsequently, laser iridotomy can facilitate aqueous outflow and provide definitive management. (Choice A) Pupillary dilation (eg, dilated funduscopic examination) narrows the corneal angle and can precipitate or worsen ACG. Therefore, mydriatic drops (eg, phenylephrine, cyclopentolate) should not be given in patients with ACG. (Choice B) Fluorescein dye can be instilled onto the surface of the eye to facilitate inspection of the cornea (eg, foreign body, corneal abrasion, keratitis). Systemic administration of fluorescein can be used to inspect the retinal circulation (ie, fluorescein angiography). These techniques are not helpful in the diagnosis of ACG. (Choice C) High-dose systemic glucocorticoids (eg, methylprednisolone) are indicated for the treatment of anterior ischemic optic neuropathy in giant cell (temporal) arteritis. They are also used in patients with optic neuritis (eg, due to multiple sclerosis). Although these conditions can cause various combinations of headache, ocular pain, and vision loss, this patient's conjunctival redness, mid-dilated pupil, and associated nausea are more consistent with ACG. (Choice E) Ophthalmic zoster (which is treated with valacyclovir) presents with eye pain, conjunctivitis, and corneal ulcers. It is usually associated with a vesicular rash in the distribution of the cutaneous branch of the first division of the trigeminal nerve [CN V]. Headache and retching are more typical of ACG. Educational objective: Initial management of angle-closure glaucoma is directed at rapidly lowering intraocular pressure. Combination therapy with multiple topical agents (eg, timolol, pilocarpine, apraclonidine) is recommended. In addition, acetazolamide rapidly reduces further production of aqueous humor. Subsequently, laser iridotomy can facilitate aqueous outflow and provide definitive management. References: Primary angle-closure glaucoma: an update. (http://www.ncbi.nlm.nih.gov/pubmed/26119516)

A 62-Year-Old Woman Is Brought to the Emergency Department Due