|Presenting Resident||Nicholas Mota, DO PGY3|
|Chief Complaint||Double vision|
|Brief HPI||30-year-old male with no past medical history presented with acute onset left ocular pain and double vision x1d. Patient states that last night he turned off the light and had immediate symptoms. Patient denies using glasses or contact lenses. Patient has never felt this before. Patient has not taken anything for the symptoms. No primary care physician. Denies any associated fever, chills, blurry vision, redness of the eye, discharge from the eye, nausea or vomiting, focal weakness, dysphagia, dysarthria, parasthesias, sob, chest pain, cough, abd pain, trauma.|
|Pertinent PE and Vitals||T: 36.4 °C HR: 86 RR: 20 BP: 146/79 SpO2: 98%
Constitutional: Alert, awake, comfortable
Neck: ROM is full and without pain, no spinous process tenderness, trachea midline
|Pertinent Labs, Pertinent Imaging/EKG (if any)||n/a|
|Working Diagnosis||Acute Angle Closure Glaucoma|
|ED & Hospital Course||Ophthalmology was consulted and requested acetazolamide 500 mg IV, mannitol 50 g IV, Combigan gtt (brimonidine/timolol), and pilocarpine gtt. Pt to f/u in office for YAG iridotomy. Patient was given drops with resultant resolution of anisocoria and APD. Patient had brother pick him up and drive him to ophthalmology office.|
|Pearls & Takeaways||Ø Glaucoma is characterized by increased intraocular pressure which will compress the optic nerve and can cause vision disturbances and, if left untreated, blindness.
Ø Aqueous humor normally drains from the posterior chamber, through the iris/lens interface into the anterior chamber, through the trabecular meshwork and out through the canal of Schlemm and into the episcleral vein.
Ø Acute angle closure attacks are mostly precipitated by pupillary dilation, increased iris/lens contact, blocked aqueous flow into the anterior chamber and increased posterior chamber pressure that causes worsening bowing or the iris against the canal.
o Tonopen: Be kind and anesthetize the eye. Instruct patient to look straight ahead. Contact cornea for 10 applanations; you do not need to indent the cornea and it may lead to incorrect readings and corneal injury. Error codes are displayed. Two numbers will appear: the first is the IOP measurement and the second (smaller) number is the statistical confidence indicator (95 is acceptable, repeat if 80 or 80-). Tonopen tip should be cleaned with canned air for 3 seconds and should occur monthly if 10 pts/week.
o Shiotz: Measures via indentation tonometry and is dependent upon scleral rigidity.
o Goldmann applanation: gold standard
Ø TREATMENT: should be in co-ordination with specialist but based on following principle: