Acute Vision Loss in a Patient With Eye Pain

Case Study

A rapid response event was initiated by a bedside nurse for a patient with acute vision loss. On arrival of first responders, the patient was lying in bed in severe pain, stating she could not see out of her right eye. Per the bedside nurse report, the patient was a 64-year-old female with a history of hypertension, heart failure, gastroesophageal reflux disease (GERD), and allergic rhinitis. She was admitted for heart failure exacerbation. A few minutes before initiating this code, the patient endorsed a sudden loss of vision in the right eye, which did not improve in the past 10 min. Upon medication review, the patient was currently being treated with furosemide for heart failure, and her home medications of lisinopril, carvedilol, and insulin were continued. She was also being given her home dose of loratadine for chronic allergic rhinitis. Her home medication of hydrochlorothiazide (HCTZ) was held inpatient while she was getting furosemide. The nurse stated the patient has been nauseous and has thrown up a few times since the pain started. The patient reported halos in her visual field and severe headache.

Vital Signs

Temperature: 98.3 °F, axillary
Blood Pressure: 145/97 mmHg
Heart Rate: 102 beats per min (bpm) – sinus tachycardia on telemetry
Respiratory Rate: 17 breaths per min
Pulse Oximetry: 97% on room air

Physical Examination

The patient was an overweight adult female lying upright in bed in acute distress. She was alert and oriented and endorsed a 10/10 right eye pain. Her eye exam showed conjunctival injection, non-reactive mid-dilated pupil on the right eye, clouded cornea, photophobia, tenderness to palpation over the right eye, and increased rigidity of the right eye ball compared to the left. A cardiovascular exam revealed tachycardia without a murmur. A quick motor and sensory exam did not reveal any acute abnormalities except for the findings in the right eye.

Interventions

The patient showed characteristic features such as acute vision loss associated with headache, nausea, conjunctival injection, photophobia, and a non-reactive mid-dilated pupil consistent with acute angle-closure glaucoma. Computed tomography (CT) scan of the head was ordered to rule out intracranial ischemic stroke/bleed. A stat ophthalmology consult was called, and recommendations were taken over the phone while waiting for them to evaluate the patient physically. Per expert recommendations, pressure-lowering eye drops were administered. Timolol maleate, apraclonidine, and pilocarpine were given 1 min apart. CT of the head was done and was normal. On arrival of ophthalmology team, tonometry was done, revealing intraocular pressure (IOP) of 40 mmHg. Once the diagnosis was confirmed by ophthalmology, acetazolamide 500 mg oral was given. The patient was retained on the floor.

Final Diagnosis

Acute angle-closure glaucoma.

Acute Angle-Closure Glaucoma

Acute angle-closure glaucoma (AACG) is defined as an acute narrowing of the anterior chamber of the eye, preventing adequate aqueous flow. This results in increased IOP. AACG is considered an ophthalmologic emergency requiring prompt identification and treatment. Characteristic findings include decreased visual acuity associated with severe eye pain, conjunctival injection, headache, nausea, vomiting, presence of halos around lights, and a pathognomonic non-reactive mid-dilated pupil. A conjunctival injection (or ‘red eye’) can be seen in various other ophthalmological pathologies, which are discussed in Table 40.1 .

Table 40.1

Differentiating features of various causes of red eye

Diagnosis	Clinical features
Iritis	Aversion to light in the affected and unaffected eye Red ring around iris = ciliary flush
Hyphema	Visible blood in the anterior chamber
Infectious keratitis	Contact lens wearer White over anterior chamber from a layer of white blood cells
Bacterial keratitis	Foreign body sensation, inflamed conjunctiva, purulent discharge
Viral keratitis	Foreign body sensation, watery discharge
Episcleritis	No pain, benign
Scleritis	Severe constant pain radiates to the face. Worse in the morning and night
Subconjunctival hemorrhage	No pain, benign, clears on its own

At-risk populations include those aged >60 years, females, Asian descent, positive family history, and use of certain medications such as loratadine and HCTZ. Delayed treatment can result in blindness which is caused by increased pressure behind the iris because of blockage of aqueous humor flow through the anterior chamber. Prolonged pressure build-up results in optic nerve damage, which causes visual disturbances shown in AACG. Angle-closure glaucoma can be classified into two main types, primary angle-closure glaucoma and secondary angle-closure glaucoma ( Table 40.2 ).

Table 40.2

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