Ophthalmology for PLAB 1

A 68 year old long-sighted woman has severe pain in her right eye with blurred vision and haloes around lights for six hours. She has vomited twice. The right eye is red, the cornea is hazy and the pupil is mid-dilated and oval, reacting poorly to light. The globe feels hard. What is the SINGLE most likely diagnosis?

1. Optic neuritis Inflammation of the nerve that carries sight signals. Pain on moving the eye, dulled colour vision, and a pupil that reacts abnormally to light, with a WHITE eye. Here, a rock-hard eye with a fixed, part-open oval pupil points elsewhere.
2. Acute glaucoma correct Correct. Sudden closed-angle glaucoma: pain, rings around lights, a hazy swollen cornea, a fixed, PART-OPEN oval pupil and a rock-hard eyeball, in a long-sighted older woman, whose short eye and shallow front chamber make her more likely to get it. The vomiting is the trap. It sends patients to a surgical or medical team while the eye itself never gets examined.
3. Conjunctivitis Inflamed eye surface. A gritty, uncomfortable feeling with discharge, NORMAL vision and a normal pupil. Never painful with loss of vision. That does not match a rock-hard eye with a fixed, part-open oval pupil.
4. Corneal ulcer An ulcer on the eye's clear front window. Pain, sensitivity to light, and a break in the surface that lights up with a dye called fluorescein, classically in someone who wears contact lenses. It does not fit a rock-hard eye with a fixed, part-open oval pupil.
5. Anterior uveitis Inflammation inside the front of the eye. Painful red eye with sensitivity to light, a SMALL, oddly-shaped pupil, and inflammatory cells seen inside the front chamber of the eye, often linked to a spine disease (ankylosing spondylitis) or bowel disease. But a rock-hard eye with a fixed, part-open oval pupil does not point to it.

The point: The red eye sorting rule: pain plus blurred vision means the eye specialist team (ophthalmology) must see the patient the same day. Sudden closed-angle glaucoma (acute angle closure) gives a hard, red eye with a fixed, part-open OVAL pupil that does not react properly, rings of light around lights (haloes), and being sick. The vomiting often sends people down a stomach-problem path, so the eye gets missed. Lie the patient flat, give acetazolamide (a drug that lowers eye pressure) plus eye drops, and refer straight away. Avoid anything that widens the pupil.

Source: NICE NG81 — Glaucoma: diagnosis and management NICE · tier 1, national regulator or guidance

A 68 year old long-sighted woman has severe pain in her right eye with blurred vision and haloes around lights for six hours. She has vomited twice. The right eye is red, the cornea is hazy and the pupil is mid-dilated and oval, reacting poorly to light. The globe feels hard. What is the SINGLE most appropriate initial investigation?

1. Gonioscopy A special mirror exam of the eye's drainage angle. It confirms the angle has closed, and it is done by the eye specialist team. That does not match a rock-hard eye with a fixed, part-open oval pupil.
2. Slit lamp examination A close-up eye exam with a special microscope. Shows the shallow front chamber of the eye, swelling of the cornea, and the part-open pupil. It does not fit a rock-hard eye with a fixed, part-open oval pupil.
3. Fluorescein staining A dye test. Finds a scratch or ulcer on the cornea, which is a different cause of a painful red eye. Here, a rock-hard eye with a fixed, part-open oval pupil points elsewhere.
4. Measure intraocular pressure correct Correct. The pressure is usually above 40, and often above 60 mmHg, against a normal upper limit of 21, which confirms the diagnosis straight away. Note that the pupil in uveitis is small and oddly shaped. The pupil is the sign that tells these two painful red eyes apart.
5. Visual acuity A vision test. Recorded for every red eye, because reduced vision is what separates the dangerous causes from the harmless ones. But a rock-hard eye with a fixed, part-open oval pupil does not point to it.

The point: The red eye sorting rule: pain plus blurred vision means the eye specialist team (ophthalmology) must see the patient the same day. Sudden closed-angle glaucoma (acute angle closure) gives a hard, red eye with a fixed, part-open OVAL pupil that does not react properly, rings of light around lights (haloes), and being sick. The vomiting often sends people down a stomach-problem path, so the eye gets missed. Lie the patient flat, give acetazolamide (a drug that lowers eye pressure) plus eye drops, and refer straight away. Avoid anything that widens the pupil.

Source: NICE NG81 — Glaucoma: diagnosis and management NICE · tier 1, national regulator or guidance

A 68 year old long-sighted woman has severe pain in her right eye with blurred vision and haloes around lights for six hours. She has vomited twice. The right eye is red, the cornea is hazy and the pupil is mid-dilated and oval, reacting poorly to light. The globe feels hard. What is the SINGLE most appropriate immediate management?

1. Acetazolamide with topical beta blocker and pilocarpine Acetazolamide, a drug that cuts down the fluid made inside the eye, with a beta-blocker eye drop and pilocarpine, a drop that shrinks the pupil and pulls the iris away from the blocked angle, while waiting for the final treatment. Here, a rock-hard eye with a fixed, part-open oval pupil points elsewhere.
2. Topical cyclopentolate A pupil-widening eye drop, used in uveitis to stop the iris sticking to the lens. It would make closed-angle glaucoma much WORSE by widening the pupil. That does not match a rock-hard eye with a fixed, part-open oval pupil.
3. Topical chloramphenicol An antibiotic eye drop. Treats a bacterial eye infection, which is a different disease with normal vision. It does not fit a rock-hard eye with a fixed, part-open oval pupil.
4. Topical corticosteroid A steroid eye drop. Treats inflammation inside the front of the eye, and it is given under the eye specialist's supervision because of the risks. But a rock-hard eye with a fixed, part-open oval pupil does not point to it.
5. Immediate ophthalmology referral correct Correct. Damage to the sight nerve begins within hours. Lie her flat, start acetazolamide with eye drops on the eye specialist's advice, and get her seen within the hour. Give nothing that widens the pupil.

The point: The red eye sorting rule: pain plus blurred vision means the eye specialist team (ophthalmology) must see the patient the same day. Sudden closed-angle glaucoma (acute angle closure) gives a hard, red eye with a fixed, part-open OVAL pupil that does not react properly, rings of light around lights (haloes), and being sick. The vomiting often sends people down a stomach-problem path, so the eye gets missed. Lie the patient flat, give acetazolamide (a drug that lowers eye pressure) plus eye drops, and refer straight away. Avoid anything that widens the pupil.

Source: NICE NG81 — Glaucoma: diagnosis and management NICE · tier 1, national regulator or guidance