Morning Report: 5/10/2012

Thanks to Dr. Yeo for today’s Morning Report on Acute Angle-Closure Glaucoma!

Acute Angle-Closure Glaucoma

Introduction:

Ocular emergency caused by sudden/increase in IOP

Prolonged increased IOP may lead to optic nerve damage and irreversible blindness

Iris is pushed or pulled anteriorly to block trabecular meshwork, blocking outflow of aqueous, leading to          increased IOP

Less than 10% of glaucoma cases in the US are due to AACG

Asians and Eskimos have anatomically narrower angles

AACG occurs in 1 of 1000 whites, about 1 in 100 Asians, and as many as 2-4 of 100 Eskimos

In white patients, AACG 3x higher in women than men

In black patients, women and men affected equally

Clinical Presentation

Dramatic symptoms: periorbital pain, blurry vision, associated ipsilateral headache, halos around objects, nausea/vomiting

Physical exam: corneal/scleral injection and ciliary flush, pain on eye movement, mid-dilated nonreactive pupil, firm globe

IOP > 21mmHG (normal 10-20mmHg)

Differential Diagnosis

Cataracts, conjunctivitis, chronic angle closure glaucoma, migraines

Management in the ED

Check visual acuity, external eye, visual fields, fundoscopic exam, pupils, ocular motility, and IOP

Topical B-blocker (i.e. timoptic), one drop

Topical a-agonist (i.e. Iopidine), one drop

Topical steroid (i.e. Predforte), one drop q15min x4, then hourly

Carbonic anhydrase inhibitor 500mg IV or PO

Mannitol 1 to 2g/kg IV

Recheck IOP hourly

Topical pilocarpine one drop 4x daily until IOP <40

Ophtho consult

Definitive treatment: peripheral laser iridectomy

TONO-PEN INSTRUCTIONS

Calibration:

1. Apply probe tip cover
2. Point tip downwards to the floor
3. Press OPERATOR BUTTON two times fast. The pen will beep and display [CAL]
4. Wait 15 seconds, the pen will beep and [CAL] will change to [UP]
5. Turn the pen up, the pen will display [Good] and then beep
6. Repeat if [bAd] is displayed
7. After [Good] is displayed, press OPERATOR BUTTON once and the pen will display [8.8.8.8] then [—-] then [====] then beep, the pen is ready

Taking a Measurement:

1. Topically anesthetize the eye
2. Position patient seated or supine
3. Instruct patient to look straight ahead at a fixed target
4. Hold pen like a pencil
5. Brace heel of hand onto cheek for stability
6. Press OPERATOR BUTTON, initially you will see [8.8.8.8] then [====] then beep
7. Touch pen to cornea lightly and briefly, repeat several times
8. A chirp will sound and measurement will be displayed each contact
9. After 4 valid readings are obtained, final beep will sound and averaged IOP will appear

*Probe tip has latex

*The pen also measures statistical reliability, under the LCD screen are four percentages (>20, 20, 10, 5). A bar will appear after the averaged IOP measurement indicating the statistical reliability of the four readings. 5% is good. 20% or greater means you should repeat the measurement of IOP.

Thanks for reading, leave any comments below!

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Jay Khadpe MD

Editor in Chief of "The Original Kings of County" Assistant Professor of Emergency Medicine Assistant Residency Director SUNY Downstate / Kings County Hospital

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