Case Presentation by Dr. Sarah Hyatt
Chief complaint: “I can’t see.
HPI: A 23 year old African American female comes into the ER because of a sudden loss of vision. She was working out in the gym when she accidentally hit herself in the eyes with an exercise band about one half hour prior to her arrival in the ED. She is very concerned because her eyes were open when this occurred. She states that she instantly experienced sudden loss of vision in her left eye. She denies any pain currently or foreign body sensation but states that she cannot see any light or movement out of her left eye. She denies any visual changes in her right eye.
PMH: asthma, sickle cell anemia
PSH: none
meds: albuterol prn
allergies: none
family history: hyperlipidemia, hypertension, sickle cell trait
Physical Exam:
Vitals: blood pressure 119/73, heart rate 75, respirations: 18, temp. 36.3
General: well nourished, well developed 23 year old female in no acute distress.
HEENT: there are no abrasions to the face. The facial bones are non-tender to palpating without palpable crepitus. When you look at the patient’s left eye you see the following:
Pupils are equally round and reactive to light, although there is pain with constriction of the left pupil. Fluorecein stain does reveal some linear uptake around 5 o’clock on the left iris, with a negative Seidel’s test. There is no uptake in the right eye. Patient has 20/30 vision on the right but sensitivity to light only on the left, without detection of motion. Slit lamp exam is unremarkable on the right and reveals an anterior chamber with a large amount of blood on the left that has a small amount settled on the bottom and without any lenticular dislocation. Ocular pressure is 12 on the right and 16 on the left.
Neuro: extra ocular movements are intact and pain free. Face is symmetric. Patient spontaneously moves all 4 extremities.
Questions:
1) What treatment should you initiate for this patient?
a) Analgesia, prompt ophthalmology consultation
b) Timolol, homatropine, eye patch, analgesia, prompt ophthalmology consultation
c) Timolol, homatropine, outpatient follow up with ophthalmology in 3-5 days
d) Timolol, homatropine, prednisolone, eye shield, follow up with ophthalmology in one week
2) What treatment should be avoided in this patient?
a) Carbonic anhydrase inhibitors
b) Topical beta blockers
c) Analgesics
d) homatropine
3) After speaking with ophthalmology and arranging follow up, we are preparing to discharge the patient. Her hyphema has started to settle and she is encouraged as she is now starting to see shapes and movement. Although it looks like the hyphema will eventually take up less than 1/3 of the anterior chamber, and she will likely do well, we counsel her that it is very important that she follow closely with an ophthalmologist as there are certain complications that she needs monitored for. What is the most common complication?
a) Re-bleeding
b) Corneal blood staining
c) Traumatic glaucoma/elevated intraocular pressure
d) Vision loss
Filed under: Question of the Week
