Clinical Case 1

Leyan Shalabi, D.O.

Julie Martino, M.D.


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


Past Medical History

Past Surgical History



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


CTA Head and Neck W WO Contrast:

Shortly after...

Ophthalmology and Neurology consults placed

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.

Imaging & Interventions


 Bilateral acute angle closure, likely due to topiramate


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:

Ophthalmology outpatient 8/15/22: 

Diagnosing Acute-Angle Closure Glaucoma


Physical Exam Findings

Conjunctival injection, fixed mid-dilated pupil measuring 5-6mm, reduced visual acuity 

Formal Criteria:

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.


Definitive Treatment & Disposition

Definitive therapy: Laser Peripheral Iridotomy (LPI)



“Acute Angle-Closure Glaucoma.” Zero To Finals,

Cargnelli, Stephanie. “Acute Angle Closure Glaucoma Review.” CanadiEM, 8 Oct. 2016,

Langridge, Colton. “Acute Angle Closure Glaucoma: ED-Relevant Management.” - Emergency Medicine Education, 21 Apr. 2017,

Lim, Annie K., et al. “Primary vs. Secondary Angle Closure Glaucoma.” EyeWiki, 10 Feb. 2023,