Discussion

Conjunctivitis may mimic other types of serious eye conditions such as glaucoma, iritis, keratitis, and corneal ulcer. Typically, conjunctivitis causes only pain, redness, and drainage, with redness sparing the limbus, the area of the conjunctiva immediately adjacent to the cornea and iris. In cases where there is photophobia, a change in vision, or injection that extends to the limbus, conjunctivitis can be ruled out.

Acute angle closure glaucoma typically presents with pain, eye redness, loss of vision, as well as headache and nausea or vomiting. Physical examination of acute angle closure glaucoma may reveal tension and tenderness in the eye, and the cornea typically appears cloudy with surrounding limbal injection and a mid-range fixed pupil. With acute angle closure glaucoma, the eye pressure is typically >40 mmHg compared with normal eye pressure of <20 mmHg or chronic glaucoma eye pressure of 20 to 40 mmHg.

Treatment of acute glaucoma involves multiple eye drops, each administered every 15 to 30 minutes in an alternating fashion to help decrease production and increase drainage of the aqueous humor of the anterior chamber. Oral acetazolamide should also be prescribed, and an ophthalmologist should be notified.


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Eye drops are typically repeated until the pressure reaches <40 mmHg and symptoms have resolved. Once sufficient pressure is reached, the patient can be discharged with maintenance eye drops and urgent ophthalmology follow-up. Refractory glaucoma may require intravenous acetazolamide and/or mannitol and emergent laser iridotomy.

The patient in this case was treated with first-line therapy including a combination of dorzolamide, brimonidine, and timolol. Second-line therapies were not necessary; after treatment in the emergency department, her right eye pressure went down to 35 mmHg. The patient was discharged to follow-up with an ophthalmologist later that day.

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Brady Pregerson, MD, is an emergency physician at Cedars-Sinai Medical Center in Los Angeles and at Tri-City Medical Center in Oceanside, California.

Reference

Pregerson DB. Ophthalmology-vision. In: Emergency Medicine 1-Minute Consult Pocketbook. http://www.erpocketbooks.com/emergency_medicine_reference_books/quick-essentials-emergency-medicine/. 2017;5.