Question

Chief Complaint A 52 y.o. accountant presents to the clinic with a sudden onset of right eye pain and redness. He believes something must have gotten in his eye while he was clearing brush in his backyard yesterday. No pain was noted during that time, but he awoke early this morning, and the pain started within an hour. He wears contact lenses and has removed them without relief. He has no history of eye problems other than farsightedness, for which he has worn monovision contact lenses for 10 or more years. He has no known medical problems and considers himself “very healthy.” He says the pain was horrible at first (10/10) and now is slightly less (8/10) but still bad. He said although he removed his contacts and his vision is generally similar in both eyes, his vision in his right eye is very blurry. Physical Examination • Vital signs: T 98.4, BP 150/95, HR 88, RR 18, HT 70, WT 215 lbs. • General: Patient holds right eye constantly during history and appears in distress. • Vision: Visual acuity, uncorrected: OS 20/60; 0D less than 20/200. Eye movements briefly assessed to be symmetrical. Pupillary responses—OS brisk and responsive; OD fails to constrict although poor tolerance of exam. OS normal structures, no lesions, redness, conjunctiva intact. OD eye is reddened and some watery tearing noted. No foreign body visible. OS funduscopic exam within normal limits. OD funduscopic exam not tolerated.

Questions

1. What three conditions would be considered in your differential diagnosis, with most likely condition listed first (with rationale)?

2. What further history, further examination, and diagnostic studies are warranted to explore your differential diagnosis? A. History B. Physical examination C. Diagnostic studies.

3. Describe the management strategies for your primary diagnosis

Answer 1

What three conditions would be considered in your differential diagnosis, with a most likely condition listed first (with rationale)?

Three most common causes suspected after considering the client’s history, presentation of symptoms and examination findings are:

· infection conjunctivitis and keratitis

· Corneal abrasion

· Acute angle-closure glaucoma

The first diagnosis to consider is a corneal infection as the patient had a feeling of something entering an eye and is a contact lens user. The patient had felt something felt in the eye, so might be that foreign body inoculated infecting organisms in the eye. Secondly symptoms started the next day not immediately. Symptoms of infections are painful eye ranging in severity from moderate to severe, redness, discharge, photophobia, decreased visual acuity or blurred vision. They are most common in contact lens users.

The second diagnosis to consider is corneal abrasion means a scratched cornea. There is a high possibility as the patient had a foreign body sensation while working with brush These are chances are high as the patient was working without wearing protective eyewear. There is a possibility that a foreign body like sand, grit or small dust or stone particle or other organic material entered in the eye, maybe dislodged under contact lens or caused lens itself to fold, both resulting in abrasion.

Corneal abrasions can be very uncomfortable and cause light sensitivity and watery eyes. Many superficial corneal scratches heal on their own. But deeper abrasions can lead to a serious eye infection and even a corneal ulcer if left untreated.

Fluorescein stain is usually linear if from trauma or foreign body, and round if from contact lens use

Acute angle-closure glaucoma another suspicion as the patient is hypertensive. Acute angle-closure glaucoma as the patient is hypertensive but his verbalization states that he is healthy, doing well and has no medical problems. So there are high chances that he may be an undiagnosed case of chronic hypertension. Contradicting to previous studies, according to new studies, long-term high blood pressure increases one's risk of developing glaucoma. Having high blood pressure for a long period will affect the eye’s ability to deal or cope with high eye pressure by creating mechanical stress and endothelial injury.

Glaucoma is a serious eye condition that occurs when there is an imbalance in production and drainage of aqueous humor (reduced or no drainage) inside the anterior chamber of the eye resulting in increased intraocular pressure. There are many types are depending on the severity of obstruction in drainage. In acute cases usual symptoms are sudden onset, severe eye pain, red-eye and reduced or blurred vision. The patient may have systemic symptoms like nausea and vomiting. Immediate treatment is needed to relieve symptoms and to prevent permanent loss of vision (severe sight impairment).

What further history, further examination, and diagnostic studies are warranted to explore your differential diagnosis? A. History B. Physical examination C. Diagnostic studies.

· History: Pattern of contact lens use, their removal, and care, hours of work, use of computers and its frequency, family history of glaucoma, symptoms of photophobia

· Physical: Assessment of eye for hardness(raised intraocular pressure)

· Diagnostic studies:

· Corneal smear examination for infection

· Tonometry to measure Intraocular pressure

· Slit-lamp examination to visualize anterior chamber of the eye

· Gonioscopy to assess drainage channels of aqueous in the anterior chamber

· Fluorescein stain for corneal ulcerations and abrasions

Describe the management strategies for your primary diagnosis

For infection

· Antibiotic eye drops and ointment

· Antiviral eye drops and ointment

· Antifungal eye drops or ointment

· Oral antibiotics if needed

For corneal ulceration

Treatment for corneal ulcers needs to be aggressive, as some ulcers lead to vision loss and blindness. Treatment usually involves antibiotics as well as antiviral or antifungal medications depending on cause.

Steroid eye drops may also be given to reduce inflammation.

Certain supplements, such as vitamin C, may be prescribed to lessen corneal scarring

For acute glaucoma

Emergency treatment is required –

To preserve the sight and prevent adhesions formation in peripheral iris to trabecular meshwork resulting in permanent closure of angle.

· Immediate administration of I.V Acetazolamide 500mg followed by oral acetazolamide 250mg qid after acute attack

· Topical beta-blockers

· Topical steroids four times daily to lower the intraocular pressure and decongest the eye