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 Painful eye movement with reduced colour vision and a relative afferent pupillary defect, and a WHITE eye. A hard eye with a fixed mid-dilated oval pupil has a red eye instead.
2. Acute glaucoma correct Correct. Acute angle closure, pain, haloes, a hazy oedematous cornea, a fixed MID-DILATED oval pupil and a stony hard globe in a long-sighted older woman, who has the short eye and shallow anterior chamber that predispose. The vomiting is the trap: it sends patients to surgical or medical assessment while the eye goes unexamined.
3. Conjunctivitis Gritty discomfort with discharge, NORMAL vision and a normal pupil. Never painful with visual loss. A hard eye with a fixed mid-dilated oval pupil is beyond it.
4. Corneal ulcer Pain, photophobia and a fluorescein-staining epithelial defect, classically in a contact lens wearer. A hard eye with a fixed mid-dilated oval pupil shows no defect.
5. Anterior uveitis Painful red eye with photophobia, a SMALL irregular pupil and cells in the anterior chamber, often with ankylosing spondylitis or inflammatory bowel disease. A hard eye with a fixed mid-dilated oval pupil shows the opposite pupil.

The point: The red eye triage: painful with reduced vision means same-day ophthalmology. Acute angle closure gives a hard, red eye with a fixed mid-dilated OVAL pupil, haloes around lights, nausea and vomiting, the vomiting sends people down an abdominal path and the eye gets missed. Lie the patient flat, give acetazolamide and topical drops, and refer immediately. Avoid anything that dilates 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 Visualises the drainage angle and confirms closure, done by ophthalmology. A hard eye with a fixed mid-dilated oval pupil makes it specialist.
2. Slit lamp examination Shows the shallow anterior chamber, corneal oedema and the mid-dilated pupil. A hard eye with a fixed mid-dilated oval pupil makes it essential.
3. Fluorescein staining Detects a corneal abrasion or ulcer, which is a different painful red eye. A hard eye with a fixed mid-dilated oval pupil makes it worth doing to exclude.
4. Measure intraocular pressure correct Correct. Pressures are typically above 40 and often above 60 mmHg against a normal ceiling of 21, which confirms it immediately. Note that the pupil in uveitis is small and irregular. The pupil is the sign that separates the two painful red eyes.
5. Visual acuity Recorded in every red eye, because reduced acuity is what separates the dangerous from the trivial. A hard eye with a fixed mid-dilated oval pupil makes it mandatory.

The point: The red eye triage: painful with reduced vision means same-day ophthalmology. Acute angle closure gives a hard, red eye with a fixed mid-dilated OVAL pupil, haloes around lights, nausea and vomiting, the vomiting sends people down an abdominal path and the eye gets missed. Lie the patient flat, give acetazolamide and topical drops, and refer immediately. Avoid anything that dilates 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 Reduces aqueous production and constricts the pupil to pull the iris out of the angle, while awaiting definitive treatment. A hard eye with a fixed mid-dilated oval pupil indicates it.
2. Topical cyclopentolate A mydriatic used in uveitis to prevent adhesions, and it would make angle closure considerably WORSE by dilating the pupil. A hard eye with a fixed mid-dilated oval pupil makes it dangerous.
3. Laser peripheral iridotomy The definitive treatment once the pressure is controlled, and it is performed on BOTH eyes because the fellow eye shares the anatomy and will otherwise do the same thing, and a hard eye with a fixed mid-dilated oval pupil here points elsewhere.
4. Topical chloramphenicol Treats bacterial conjunctivitis, which is a different disease with normal vision. A hard eye with a fixed mid-dilated oval pupil makes it the wrong target.
5. Immediate ophthalmology referral correct Correct. Optic nerve damage begins within hours. Lie her flat, start acetazolamide with topical treatment on ophthalmic advice, and get her seen the same hour, and give nothing that dilates the pupil.

The point: The red eye triage: painful with reduced vision means same-day ophthalmology. Acute angle closure gives a hard, red eye with a fixed mid-dilated OVAL pupil, haloes around lights, nausea and vomiting, the vomiting sends people down an abdominal path and the eye gets missed. Lie the patient flat, give acetazolamide and topical drops, and refer immediately. Avoid anything that dilates the pupil.

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