Clinical Case 1
Leyan Shalabi, D.O.
Julie Martino, M.D.
HPI
32 year old female with history of endometriosis, panic attacks, vertigo, restless leg syndrome, and recent admission for vertigo presents with vision loss. She reports that today she initially started having blurry vision. She was looking at her daughter and the items behind her daughter were blurry. She saw the optometrist prior to coming into the ER who reportedly noted a slight decrease in her acuity bilaterally compared to last year. The blurry vision progressed to complete vision loss aside from seeing gross movement. She endorses a frontal headache and associated nausea. She has had a history of migraines but reports that this feels different than previous headaches. During her last admission, she was prescribed Meclizine, Topamax along with Mirapex. She denies vomiting, paresthesias, weakness.
Review of Systems
Constitutional: Negative for chills and fever.
HENT: Negative for congestion and trouble swallowing.
Eyes: Positive for visual disturbance. Negative for pain and discharge.
Respiratory: Negative for apnea and chest tightness.
Cardiovascular: Negative for chest pain and leg swelling.
Gastrointestinal: Negative for abdominal distention and abdominal pain.
Endocrine: Negative for cold intolerance and heat intolerance.
Genitourinary: Negative for difficulty urinating and dysuria.
Musculoskeletal: Negative for arthralgias and back pain.
Skin: Negative for color change and pallor.
Neurological: Positive for headaches. Negative for facial asymmetry and numbness.
Hematological: Negative for adenopathy. Does not bruise/bleed easily.
Psychiatric/Behavioral: Negative for agitation and behavioral problems.
Physical Exam
Vitals: BP: 116/69, P 70, T 98.1F, RR 13, SpO2 100%
Constitutional: No acute distress, resting comfortably in bed
Eyes: No scleral icterus, EOM intact. Visual acuities unable to be obtained. Visual fields intact. RAPD: none. Pressures: L 21 R 17. Fluorescein stain: no uptake
CV: Regular rate, regular rhythm, normal S1 and S2, no murmurs, rubs, or gallops. 2+ radial, DP and PT pulses bilaterally. No lower extremity edema bilaterally
Resp: Normal respiratory effort, lungs CTA without crackles or wheezes. Equal breath sounds bilaterally
GI: abdomen soft, non-distended, normoactive bowel sounds, non-tender throughout. No rebound, guarding, or rigidity
GU: No tenderness with percussion of bilateral CVA
MSK: Head is normocelphalic/atraumatic. Neck is supple. No anterior chest wall TTP. Extremities with no deformities, cyanosis, or clubbing.
Skin: Warm and dry
Neuro: Alert and oriented. Moves all extremities spontaneously
Pscyh: Appropriate mood and affect, cooperative with exam
History
Past Medical History
Left ovarian cyst
Endometriosis
Cholelithiasis
Numbness and tingling in both legs
Chronic migraine with aura
Vertigo
Past Surgical History
Laparoscopic gastric sleeve surgery (2018)
Cesarean section
Laparoscopic cystectomy L (2021)
Laparoscopic uterine nerve ablation (2018)
Labs
CBC
WBC 6.0
RBC 4.18
HGB 12.4
HCT 35.6↓
MCV 85.2
MCH 29.7
MCHC 34.8
RDW-CV 12.8
RDW-SD 39.2
PLT 196
ESR: <1
Basic Metabolic Panel
Na+: 138
K+: 3.8
Cl-: 110
CO2: 23
Anion Gap: 9
Glucose: 119↑
BUN: 10
Cr: 0.71
GFR: >90
BUN/Cr: 14
Ca2+: 9.4
Imaging
CTA Head and Neck W WO Contrast:
Shortly after...
Ophthalmology and Neurology consults placed
2136: Patient noted to have R eye fixed with haziness over cornea with IOP 50s-60s
2156: Upon reevaluation L eye becoming more dilated with IOP in 40s-50s, patient became bradycardic to 30s with BP 90s systolic
So... what is causing these headaches, vision changes, and now hemodynamic instability?
Click to view answer
Bilateral acute-angle closure glaucoma
Culprit? .... Topiramate
Hindsight is 20/20.
7/20/22: Seen and admitted for recurrent vertigo, migraine with aura, tinnitus. MRI brain/auditory canals unremarkable, diagnosed with vestibular migraines -> discharged home with 25mg topiramate for headache preventive agent
7/27/22: seen by neurology clinic, topiramate increased to 50mg BID
7/30/22: symptom onset bilateral blurred vision
Bradycardia and hypotension 2/2 vasovagal episode, improved with no interventions
Imaging & Interventions
Ophthalmology:
Bilateral acute angle closure, likely due to topiramate
IOP 55 R, 25 ->40 L
Started Cosopt, brimonidine drops, one dose 500mg Diamox IV, prednisolone acetate
Repeat IOP 22 R, 15L on drop therapy
Neurology:
Recommending MRI brain w/ wo
7/30/22: MRI brain w/wo: Normal MRI brain, Findings suggest a diffuse orbital scleritis, Correlate clinically
Neurology outpatient 8/3/22:
Will follow peripherally and await ophtho recommendations
Ophthalmology outpatient 8/15/22:
Still with bilateral blurry vision, intermittent right eye pain
Repeat eye exam with bilateral papilledema, no glacomatous optic nerve damage, IOP normalized, open angles
Recommended follow up with neurology for LP to assess for IIH
Diagnosing Acute-Angle Closure Glaucoma
HPI
HA, eye pain, vision changes, nausea, vomiting
Precipitating causes
Anything that causes pupillary dilation increases risk!
Risk factors
Women, Asian descent
Older patients (60s+)
Family history
Physical Exam Findings
Conjunctival injection, fixed mid-dilated pupil measuring 5-6mm, reduced visual acuity
Formal Criteria:
2 complaints/symptoms:
Ocular pain, intermittent visual blurring, nausea, vomiting
3 signs:
IOP greater than 21 mm Hg, corneal edema, conjunctival injection, mid-dilated pupil, shallow anterior chamber
Disposition and Treatment
Immediate ophthalmology consultation ASAP!
Don’t be short-sighted, time= optic nerve!
Supportive Treatment
Don't turn a blind eye- give adequate pain control and antiemetics as needed.
Management
Timolol 0.5%
1 drop q12 hours
Brimonidine 0.15%
1 drop, can repeat once in 1 hr
Diamox
500mg PO or IV
If IOP >40mm Hg use IV
125-250mg q4hr
If IOP still >35 at 30-60 minutes -> Osmotic agents
Mannitol 0.5-1.5g/kg 15 to 20% solution
↓IOP 30 mm Hg
Glycerin 1 to 1.5 g/kg 50% solution
Isosorbide 1 to 1.5 g/kg 45% solution
Definitive Treatment & Disposition
Definitive therapy: Laser Peripheral Iridotomy (LPI)
Performed within 24-48 hours
Needs medical management to optimize visibility and procedure
Disposition:
Admit
References
“Acute Angle-Closure Glaucoma.” Zero To Finals, https://zerotofinals.com/medicine/ophthalmology/acuteglaucoma/.
Cargnelli, Stephanie. “Acute Angle Closure Glaucoma Review.” CanadiEM, 8 Oct. 2016, https://canadiem.org/medical-concepts-acute-angle-closure-glaucoma/.
Langridge, Colton. “Acute Angle Closure Glaucoma: ED-Relevant Management.” EmDOCs.net - Emergency Medicine Education, 21 Apr. 2017, http://www.emdocs.net/acute-angle-closure-glaucoma-ed-relevant-management/.
Lim, Annie K., et al. “Primary vs. Secondary Angle Closure Glaucoma.” EyeWiki, 10 Feb. 2023, https://eyewiki.aao.org/Primary_vs._Secondary_Angle_Closure_Glaucoma#Acute_angle_closure_glaucoma.