Identify the Condition

A 66 y/o M with pmh of HTN presents to the ED for evaluation of acute onset right eye pain, blurred vision, nausea and vomiting.  The patient reports being in his usual state of health until he took a small dose of benadryl to help him sleep.  

Please identify this patient’s condition and comment on its management.  

Answer: Acute Angle Closure Glaucoma

- Ocular emergency → immediate treatment as well as ophthalmology evaluation needed

- Acute increase in intraocular pressure caused by outflow obstruction of aqueous humor from the anterior chamber of the eye; IOP usually > 20mmHg, can be much higher.  

- History and Exam often significant for - eye pain, nausea/vomiting, history of intermittent blurred vision with halos, ipsilateral headache; Physical Exam - increased IOP, mid-dilated nonreactive pupil, conjunctival injection, blurred vision

- PRECIPITATING FACTORS: Drugs (sympathomimetics, anticholinergics (benadryl), SSRIs, sulfonamides, cocaine, botox); dim light, and rapid correction of hyperglycemia.

- ED Rx → IOP reduction, suppression of inflammation, and the reversal of angle closure.

  • Topical Beta-blockers, alpha-agonist and acetazolamide → decrease aqueous humor production and enhance opening of the angle
  • Topical steroids → decrease inflammation and reduce optic nerve damage
  • Rx extraocular manifestations → pain control and antiemetics
  • Reassess after initial intervention → If IOP still high, consider osmotic agents
  • Pilocarpine, a miotic agent that causes opening of the angle, may be effective after initial lowering of IOP

Dispo: Low threshold for admission; if osmotic agents used patients may require electrolyte and volume status monitoring

Happy Studying,

Doc Roddy