Who you are:
You are an FY2 doctor working in the Emergency Department.Who the patient is:
Mrs. Hilary Green, an-59-year old lady, presented with sudden onset on set of severe pain in her left eye.Additional information:
None.Special information:
None.What you must do:
Please talk to Mrs. Green, take a focused history and discuss the management plan with her.
Patient information:
- She has pain around her eye and on the side of her head ( temporal area ).
- Sharp, sudden eye pain started 4 hours ago.
- Pain score - 9/10
- Red eye and have got headache above the eye.
- She was washing dishes with her husband when the pain started.
- Nauseous and vomited once.
- She was diagnosed with depression/back pain 6 months ago and she is
- taking Amitriptyline 25mg once at night for depression/back pain.
- She is wearing Dark Sunglasses because she doesn’t want people see
- her red eye and the light hurts.
- She is married with 2 children and doesn’t want to be admitted.
- Symptoms of Acute Closure Angle Glaucoma :
- Intense eye pain (Red Flag) Nausea and vomiting
- A red eye
- A headache
- Tenderness around the eyes Seeing rings around lights Blurred vision
Data Gathering
Introduction:
D: Hello, I am Dr (name ) one of the doctors working in the General
Practice. May I know your full name please?
D: May I know your age please?
D :Could you please tell me what happened? - I have pain in my left eye.
P1 SOCRATES
D: Could you please tell me more about it?
D : Which eye?
D: What about the other eye ?
D: Was it sudden or gradual?
D: When did it start? - It started a few hours ago.
D: What were you doing when the pain started ? - Watching TV
D : Has it gotten better or worse?
D: Anything making it better or worse ?
D: Have you tried anything ? - PCM
D: How much did you take? - 2
D: What type of pain is it? - Dull
D: Does the pain go anywhere?
D: Is it continuous or does it come and g o ? - Continuous
D: Does the pain go anywhere?
D: Can you score the pain from 1 to 10, 1 being the no pain and 10 being the worst pain you have ever experienced? - 7
D: Are you able to see ? -
D: Any problem with your vision ? - Blurry vision.
D : Anything else ? - headache
D: SCORATES
DD :
EYE DD +
Any burning sensation, any gritty sensation, or any sticky discharge?
(Conjunctivitis) - No.
Any joint pain? Wee problem? (Reiter’s) - No.
Any halos around light ? - Yes
P 2
Drive ICE
Examination
- General physical examination
- Vitals ( Temperature, O2sat , HR, RR, BO)
- Check the pressure in the Eye
- Visual acuity/ Visual field
Diagnosis & Explanation
- Thank you for baring with me so far. From what you have told me and from the examination, I suspect you have a condition called Acute Angle Closure Glaucoma. It’s caused by sudden blockage in the drainage of our eye which raised the pressure inside the eye and causing this type of sudden pain.
Management
- Mainly to reduce the pressure in the eye
- Admit
- Ophthalmologist
- Pilocarpine eye drop
- Acetazolamide
- Painkillers
- Anti - emetics
- Investigation
- Slit lamp examination
- FBC, LFT, KFT, U&E, Blood sugar, CRP, ESR, Clotting factors
- Gonioscope - examine outflow channels around the trabecular mesh work area of the eye.
- Once pressure is normalized-
- Laser or surgery which makes a small hole in the iris.
- This allows fluid to flow freely around the iris and stop bulging and blocking the trabecular mesh work in the future.
- Laser - peripheral iridotomy Surgical - surgical iridotomy
Notes :
- Do not cover the eye. (if wearing sunglasses- remove ) - it can dilate worsen the situation.
- Do Not lie down in a dark room - it can increase the pressure / dark room will dilate the pupil further.
- If Pt is taking amitriptyline - stop and refer back to the specialist to adjust the medication. Alternative as Citalopram for depression / Gabapentin and Pregabalin for back pain. (reason could be due to the drug - amitriptyline)
Concern
- Pt: I didn’t expect to go to hospital today, I can’t stay at hospital?
- I understand that you didn’t expect that, but is there any particular reason why you cannot stay in hospital?
- I’m sorry to tell you that it is a threatening condition which means it can affect your vision that’s why we need to try it ASAP
- What if we try and arrange (look for solutions), would that be acceptable for you?
- Do Not Drive Leaflets