>> Acute Angle Closure Glaucoma
Presentation:
Extremely painful (deep, boring pain); frequently associated with vomiting
Exam:
A red, angry appearing eye, firm to touch
Cloudy “steamy” cornea
Decreased visual acuity (may be profound)
Markedly elevated IOP (generally > 40 mm Hg)
Management:
Treat pain and give antiemetic
Consult Ophthalmologist emergently
Carbonic anhydrase inhibitors - Acetazolamide
Topical beta blockers - Timolol
Mannitol or Glycerol IV
Alpha agonist drops - Apraclonidine
Definitive therapy is surgical; involves laser iridectomy
>> Optic Neuritis
Causes: Multiple sclerosis (1/3 of patients with optic neuritis will develop MS), Other causes - idiopathic, infections (syphilis, measles, TB, crypto, etc), and autoimmune diseases
History:
Painful monocular vision loss
Pain behind eye and with eye movements
Exam:
Loss of central vision; peripheral vision is preserved
Afferent pupillary defect (APD)
Anything that affects the optic nerve will cause an APD
Not specific to optic neuritis; may occur in any condition where light cannot reach the retina
Red desaturation test
Take a dark red item and have the patient look at it covering one eye and then the other
Affected eye will see it as lighter red or pink
Management:
Consultation with Ophthalmology and Neurology are both appropriate
MR brain looking for plaques of MS
Admit for IV steroids (Methylprednisolone); very high doses are used
>> Giant Cell Arteritis
History:
Painful monocular vision loss
May have headache, especially over the temporal areas
Strong association with Polymyalgia Rheumatica (painful chronic condition in older patients causing fatigue and muscle pain)
Jaw claudication (aching pain with chewing) is an important clue
Exam:
Palpate and inspect area near temporal arteries for tenderness and nodularity
Management:
Patients with any visual loss should be admitted for IV steroids
Methylprednisone 0.5-1 gm daily x 3 days (similar to optic neuritis or MS)
If no vision loss, you can start Prednisone 1 mg/kg PO
ESR should be draw; temporal artery biopsy should then be performed in the next week to confirm diagnosis