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ADMISSIONS CONFERENCE

ADMISSIONS CONFERENCE. Pamela Marie B. Imperial December 10, 2011. IDENTIFYING DATA. ACUIN, Mercy Perez 57 / Female Married Filipino Roman Catholic From Pangasinan Admitted: Dec. 9, 2011. CHIEF COMPLAINT. Eye redness, left (< 2 weeks). HISTORY OF PRESENT ILLNESS.

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ADMISSIONS CONFERENCE

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  1. ADMISSIONS CONFERENCE Pamela Marie B. Imperial December 10, 2011

  2. IDENTIFYING DATA • ACUIN, Mercy Perez • 57 / Female • Married • Filipino • Roman Catholic • From Pangasinan • Admitted: Dec. 9, 2011

  3. CHIEF COMPLAINT • Eye redness, left (< 2 weeks)

  4. HISTORY OF PRESENT ILLNESS

  5. PAST MEDICAL HISTORY • No hypertension, diabetes mellitus, asthma, or COPD • No previous surgeries • No previous eye diseases; does not wear spectacles

  6. FAMILY HISTORY • No diabetes mellitus, asthma • Hypertension (sister) • No glaucoma

  7. PERSONAL-SOCIAL HISTORY • Housewife • Born and raised in Bicol; HS graduate • Lives in Pangasinan with husband & eldest son • No Philhealth, health insurance • Nonsmoker, nondrinker; denies illicit drug use

  8. REVIEW OF SYSTEMS • No nausea/vomiting • No headache • No dizziness • No flashes of light • No eye itching • No eye discharge • No abdominal pain

  9. OPHTHALMOLOGIC EXAM

  10. OPHTHALMIC EXAM

  11. PHYSICAL EXAM • General Survey • Conscious, coherent, not in cardiorespiratory distress • Vital signs • BP130/90 HR82 RR18 T37 ºC • HEENT • Anicteric sclera, pink palpebral conjunctivae, no tonsillopharyngeal congestion, no cervicolymphadenopathies • Chest/lungs • Equal chest expansion, clear breath sounds, no retractions • CVS • Adynamicprecordium, normal rate, regular rhythm, distinct S1 and S2, no murmur • Abdomen • Flat abdomen, normoactive bowel sounds, (-) tenderness on deep palpation, (-) CVA tenderness • Extremities • With full and equal pulses, no cyanosis, no edema, no pallor, no deformities

  12. PRIMARY IMPRESSION • Acute Angle Closure Glaucoma, OS

  13. DIFFERENTIALS UVEITIS Small, irregular pupils Minimal pupillary response Normal depth AC Dull, swollen iris Flare and cells in AC IOP not usually elevated • Moderately severe pain • More photophobia • Some visual loss • +/- Lacrimation • Cornea not usually hazy • Deep ciliary injection

  14. DIFFERENTIALS CONJUNCTIVITIS Clear cornea Normal depth AC Pupil response & IOP normal • Little (burning) or no pain • No visual loss • Eye discharge • Inflamed conjunctiva • No ciliary injection

  15. MANAGEMENT PLAN • DIET: as tolerated • IVF: PNSS 1 L to run at KVO • MEDS: • Timolol • Brimonidine • Acetazolamide • Mannitol 300 mL IV every 6 hours

  16. TESTS: • CBC, UA, FBS, NA, K, Cl, BUN, Crea • CXR, 12L-ECG • For Trabeculectomy, OS

  17. DISCUSSION

  18. DEFINITION OF GLAUCOMA • Potentially progressive and characteristic optic neuropathywhich is associated with visual field loss as damage progresses, and in which intraocular pressure is usually a key modifying factor

  19. EPIDEMIOLOGY • 2% of those >40 years old; 10% over age 80 • POAG most common form in Europeans & Africans • Primary angle closure high prevalence in Far Easterners

  20. CLASSIFICATION • Congenital vs. Acquired • Open angle vs. Angle-closure • Primary vs. Secondary

  21. AQUEOUS PATHWAY • IOP determined by rate of aqueous production & resistance to outflow of aqueous • 250 μL; clear liquid, fills eye chambers • Similar to plasma but with  ascorbate, pyruvate & lactate;  protein, urea, glucose • Diurnal variation in production

  22. PHYSIOLOGY OF AQUEOUS PRODUCTION

  23. ACUTE ANGLE-CLOSURE GLAUCOMA • Occlusion of the trabecular meshwork by the peripheral iris (iridotrabecular contact ), obstructing aqueous outflow • Primary – anatomic predisposition • Secondary – to another ocular condition

  24. PATHOPHYSIOLOGY OF ACUTE ANGLE-CLOSURE GLAUCOMA

  25. PATHOPHYSIOLOGY OF ACUTE ANGLE-CLOSURE GLAUCOMA • IOP 60-80 mmHg  iris ischemia, corneal edema, optic nerve damage • Retinal ganglion cell apoptosis  thinning of inner nuclear nerve fiber layers, axonal loss in the optic nerve • Optic disk atrophy, enlarged optic cup

  26. RISK FACTORS FOR ANGLE-CLOSURE DEMOGRAPHIC OCULAR Hyperopia Shallow anterior chamber Steep corneal curvature Thick crystalline lens Short axial length • Family history • Older age (ave. 60) • Female sex • Asian/Inuit descent

  27. CLINICAL PRESENTATION • Sudden onset visual loss or BOV, usually peripheral • Periorbital pain • Ipsilateral headache • Haloes around flashes of light • Nausea/vomitng, abdominal pain • Precipitated by dim light or medications eg. anticholinergics, sympathomimetics

  28. SIGNS Steamy cornea Ciliary flush Fixed, mid-dilated pupil Shallow anterior chamber

  29. EXAM TECHNIQUES • GONIOSCOPY • Cornea-air interface creates “total internal reflection” • Goniolens used to look directly at the angle

  30. TREATMENT MEDICAL SURGICAL Laser peripheral iridotomy Widens angle by 2 grades Trabeculectomy Fellow eye should also be operated on as prophylaxis • Reduce aqueous production • Increase outflow • Decrease inflammation

  31. COMPLICATIONS • Anterior synechiae formation • Irreversible occlusion of the angle • Optic nerve damage

  32. Thank You!

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