Presenting complaint:

– Painful red eye

Symptoms:

– Site: Left eye 

– Onset: Started suddenly, over a matter of minutes, while watching TV

– Character: Sharp, throbbing pain all over the eye 

– Radiation: Radiates through head with associated headache

– Associated Symptoms: Nausea, she has vomited 3 times since the onset of her symptoms, associated throbbing headache. She is struggling to see with her left eye

– Timing: 1 hour since onset of her symptoms

– Exacerbating and Relieving Factors: Nothing is making the pain better

– Severity: 9/10 pain

Other relevant positive and negative findings:

– No history of any injury to the eye

– This has never happened before

– Her eye is red & watering but not exuding pus. Mild swelling present

– Her vision has become more blurry in her left eye and she is struggling to look at bright light

– If asked about if she sees halos around lights: yes

– No eye grittiness/dryness

– No eye itching

– No flashes or floaters in vision

– No “curtain coming down” on vision

– She wears glasses and has a number of +2.25 in her R eye and +2.50 in her L eye. (Hypermetropia)

Systemic Symptoms:

– Fatigue: None

– Fever: None

– Night Sweats: None

– Unintended Weight Loss: None 

– Chest or Shoulder Tip Pain: None 

– Shortness of Breath or Cough: None 

– Oedema: None 

– Rashes or Skin Changes: None 

– Headache: 9/10 severe headache, throbbing, constant

– Mood Changes: None

– Sleep Disturbances: None. 

– Change in Bowel Habits: None

– Urinary symptoms: None 

Past Medical History:

– Migraines since she was in her early 20s

– Eczema

– No other relevant PMHx

Drug History:

– Amitriptyline

– Uses over-the-counter 1% hydrocortisone for eczema, in addition to emollients

Allergies:

– NKDA

Family History: 

– Patient’s mother had migraines

Social History:

– Occupation: She trained as an accountant but has now reduced her work duties to spend more time with her grandchildren

– Lifestyle: She tries to stay active and does regular yoga. Eats balanced meals as much as she can, usually containing big portions of cooked and raw vegetables, meat and fish

– Activities of Daily Living and Hobbies: Very active, doing well for her age, goes on 20 km walks with her friends every weekend in the countryside

– Pets at home: A cat named Cindy 

– Smoking: Never smoked

– Alcohol: Occasionally drinks alcohol socially, perhaps 1 or 2 cocktails at a bar with her friends every other month

– Recreational Drug Use: Never used

Ideas, Concerns, and Expectations: 

– Ideas: “I have no idea what is going on doctor, this has never happened before!”

– Concerns: “I am concerned that I may lose my vision in my left eye.”

– Expectations: ”Please help me doctor, please give me some medication to make this stop!”

Observations: 

• Respirations (Breaths/min): 15
• Oxygen Saturation (%): 99%
• Air or Oxygen?: Air
• Blood Pressure (mmHg): 110/67 
• Pulse (Beats/min): 100
• Consciousness (AVPU): A
• Temperature (Celsius): 37.1

NEWS Total Score: 2

Eye Examination: 

General Inspection

– Patient appears unwell and in visible discomfort

– Sitting with eyes partially closed, avoiding bright light (photophobia)

– Left eye appears red, congested, watery and mildly swollen with corneal oedema

Inspection with Pen Torch

Author: Jonathan Trobe, M.D. Source: The Eyes Have It. Wikimedia Commons. CC BY 3.0.

– Left eye: Ciliary injection, hazy (oedematous) cornea, shallow anterior chamber (crescentic shadow seen on oblique lighting)

– Right eye: No abnormal findings; deeper anterior chamber noted

Pupillary Assessment

– Left pupil: Mid-dilated, fixed, sluggish response to light

– Right pupil: Normal size, round, brisk direct and consensual responses

– No relative afferent pupillary defect (RAPD) noted

Visual Acuity (VA)

Unaided:

– Left eye (OS): Markedly reduced – able to count fingers at 1 metre

– Right eye (OD): Slightly reduced – 6/9 unaided

With correction (spectacles):

– Left eye: No significant improvement due to corneal oedema

– Right eye: Improves to 6/6 with +2.25D hyperopic correction

Visual Fields

– Gross confrontation fields appear normal in the right eye

– Unable to reliably assess the left eye due to pain and visual impairment

Eye Movements

– Full range of movement in both eyes

– No diplopia

– Movements are painful in the left eye, particularly on elevation

Fundoscopy

– Left eye: Fundus view obscured due to corneal oedema

– Right eye: Normal optic disc with sharp margins, healthy macula and vessels

Intraocular Pressure (if measured)

– Left eye: Elevated intraocular pressure (e.g. >50 mmHg)

– Right eye: Normal intraocular pressure

Patient Questions: 

1. “Doctor, what is happening to me?” 

Exemplar answer: “You’ve had a sudden increase in pressure inside your left eye, which is causing pain and blurred vision. This condition is called acute angle closure glaucoma, and it needs urgent treatment — which we’ve already started — to protect your sight.”

2. “Could this have been prevented by me? I try to stay healthy . I don’t know what happened!”

Exemplar answer: “You’ve done nothing wrong. This condition can happen to healthy people, especially those with certain eye shapes, like being long-sighted. It’s not something you could have predicted or prevented.”

3. “Will you be able to cure me?”

Exemplar answer: “With prompt treatment, we can relieve the pressure and prevent further damage. You may need a laser procedure to stop this from happening again. While we can’t undo any damage already done, we’re doing everything we can to protect your vision going forward.”

Examiner Questions: 

1. What is the most likely diagnosis? 

Acute angle closure glaucoma 

2. Name four risk factors from the history for AACG 

Possible answers: 

– Increased age 

– East Asian or Inuit ethnicity 

– Female 

– Use of medication that can induce angle narrowing, such as amitriptyline 

– Far-sightedness (hypermetropia) 

– Shallow anterior chamber

3. How would you differentiate AACG from anterior uveitis? 

AACG presents with high intraocular pressure, a mid-dilated fixed pupil, and corneal oedema, whereas anterior uveitis typically shows a small, irregular pupil with photophobia and may have keratic precipitates on slit lamp examination. Intraocular pressure in uveitis may be normal or low initially, with an open angle on gonioscopy.

4. What is the role of pilocarpine in AACG and when should it be given? 

Pilocarpine is a miotic agent that constricts the pupil and pulls the iris away from the trabecular meshwork, helping open the drainage angle. However, it should only be used after intraocular pressure begins to fall, as a very high IOP may render the iris ischaemic and unresponsive.

5. What are the main investigations required? 

Diagnostic Tests:

• Fundoscopy: To rule out conditions such as optic neuritis. May show evidence of damage to the optic nerve due to raised pressure, e.g. large optic cup and nerve fibre loss
  • Findings in this case: corneal oedema
• Slit lamp examination: To rule out other conditions causing acutely painful red eye such as anterior uveitis
  • Findings in this case: Conjunctival injection, cloudy cornea, shallow anterior chamber, mid-dilated, fixed pupil
• Goldmann applanation tonometry: measures intraocular pressure, would show raised IOP in conditions such as acute angle closure glaucoma
  • Findings in this case: Pressure of 51mmHg (normal 10-21mmHg)
• Gonioscopy: to measure angle closure (GOLD STANDARD diagnostic test)
  • Findings in this case: closed angle seen
• Retinal optical coherence tomography: Can be used to assess loss of nerve tissue in and around the optic nerve objectively and quantitatively

6. What are the differentials for AACG, and how would you differentiate between them? 

7. Please elaborate on the management of AACG

Treatment:

– AACG is a sight-threatening emergency
– It requires same-day ophthalmology referral and often hospital admission

Immediate management: 

– Lower intraocular pressure (IOP) rapidly: Lie the patient down on their back without a pillow

– Pilocarpine eye drops 

– Acetazolamide 500mg orally

– Analgesia and antiemetics if required

Medical management: 

Definitive treatment: 

Management of the unaffected eye: 

– Even if asymptomatic, the other eye is at high risk
– Perform prophylactic laser iridotomy in the unaffected eye