OPHTHALMOLOGY
GLAUCOMA
PromptACUTE (CLOSED ANGLE) glaucoma
Response
PromptTypical history of acute angle closure glaucoma
ResponseSevere unilateral painShort duration (minutes to hours - longest stem was 12h)
+/- visual changes
N+V
Visual loss/Halo
+/- visual changes
N+V
Visual loss/Halo
PromptClinical findings in glaucoma
ResponseNon reactive to light
Pupil Mid size
Pupil irregular
Ciliary injection (ie: redness just next to iris as opposed to generally - pic opposite shows lateral ciliary injection)
Cloudy/hazy cornea
Markedly increased IOP (>35 mm.Hg)
Pupil Mid size
Pupil irregular
Ciliary injection (ie: redness just next to iris as opposed to generally - pic opposite shows lateral ciliary injection)
Cloudy/hazy cornea
Markedly increased IOP (>35 mm.Hg)
PromptMethods of measuring intraocular pressure
ResponseElectronic indentation - tonopen
Impression (schiotz) tonometry
Applenation tonometry with slit lamp (goldmann)
Rebound tonometry
Impression (schiotz) tonometry
Applenation tonometry with slit lamp (goldmann)
Rebound tonometry
PromptWhat is normal IOP
Response<20-22 mm.Hg. If IOP>40 suggestive of acute glaucoma
PromptED management of acute glaucoma
ResponseUrgent ophthalmology consultation (vision threatening) - Needs laser
Acetazolamide 500 mg PO/IV (carbonic anhydrase inhibitor) - decrease production of aqueous humour
Pilocarpine eye drops 2% 1 drop Q15 min until constricted (parasympathetic Cholinergic agent) - Increase outflow of aqueous humour + constricts pupil
Apraclonidine drops 1% 1-2 drops as single dose (alpha blocker >> decreased aqueous humour production, increased outflow)
Timolol drops 0.5% 1-2 drops - Decrease production of aqueous humour
Mannitol 1-2 g/kg over 45 mins - (osmotic diuresis) - decrease volume of aqueous humour
Head up 30 degrees
Analgesia
Antiemetics
STAMPS - Supine position, Timolol, Acetazolemide/Apraclonidine, Mannitol, Pilocarpine, Supportive
Acetazolamide 500 mg PO/IV (carbonic anhydrase inhibitor) - decrease production of aqueous humour
Pilocarpine eye drops 2% 1 drop Q15 min until constricted (parasympathetic Cholinergic agent) - Increase outflow of aqueous humour + constricts pupil
Apraclonidine drops 1% 1-2 drops as single dose (alpha blocker >> decreased aqueous humour production, increased outflow)
Timolol drops 0.5% 1-2 drops - Decrease production of aqueous humour
Mannitol 1-2 g/kg over 45 mins - (osmotic diuresis) - decrease volume of aqueous humour
Head up 30 degrees
Analgesia
Antiemetics
STAMPS - Supine position, Timolol, Acetazolemide/Apraclonidine, Mannitol, Pilocarpine, Supportive
PromptSupportive medcications
ResponseAntiemetics (eg: ondansetron 8 mg)
Analgesia (Eg: Morphine 2.5mg alliquots)
Analgesia (Eg: Morphine 2.5mg alliquots)
PromptShort stay appropriate? Opthal reg pushing for it
ResponseNO.
Explain inappropriate. May require definitive surgical management. Needs hospital admission for close monitoring and treatment
Decreased visual accuity suggests severe case at risk of permanent/irreversible vision damage/loss
Escalate if registrar resistant - Speak to consultant
Explain inappropriate. May require definitive surgical management. Needs hospital admission for close monitoring and treatment
Decreased visual accuity suggests severe case at risk of permanent/irreversible vision damage/loss
Escalate if registrar resistant - Speak to consultant