ERDoc Posted July 13, 2007 Author Share Posted July 13, 2007 I'll echo the other's with a request for an initial assessment. Let's see what she was doing when this whole thing started? What change prompted her to call for the ambulance today? What is her medical history? Meds? Allergies? Has this ever happened to her before? Vital signs including skin color/temp? Has she ever seen her physician for something similar in the past? Any pain anywhere? While we're checking her pupils, how is her occular motor function? Can she control her eye without trouble? Or with a rull range of motion? Shane NREMT-P Ahh. Finally some good questions. I guess no one is up for a good ophtho case (or is it? :wink: ). The pain wasn't sudden in onset. I developed gradually as I described. The daughter called EMS because she became concerned when the pt told her she couldn't see in the eye anymore. "It's not a big deal, I've got another." Has a history of hypertension and cataracts. She had surgery on the other eye to correct her cataract. She was supposed to have surgery on the left eye, but never followed up. Takes Lisinopril. No allergies. Vitals are 126/72, 82, 14, 99%RA, 98.6. Has never had anything like this before. No pain at this time. The right pupil is irregular in shape and minimally reactive. The left pupil is round, 6mm and nonreactive. The eye is very red and tearing. Extraoccular muscles are intact. Both lids are swollen slightly. The iris appears to be touching the inside of the cornea. Link to comment Share on other sites More sharing options...
vs-eh? Posted July 13, 2007 Share Posted July 13, 2007 Any recent falls prior to the onset 3 days ago? Basal skull issues/injury? Obviously my opthalmology knowledge is quite limited but perhaps a cranial nerve issue or an ischemia/injury/infarct issue which my explain why she has no pain now? Maybe she gets some type of cool cybernetic eye? Or maybe, just maybe...No, it couldn't be....SHE IS A CYBORG! Doc, you cheeky monkey you... Link to comment Share on other sites More sharing options...
AnthonyM83 Posted July 13, 2007 Share Posted July 13, 2007 Did she try to do anything to left eye, perhaps a home remedy gone wrong? No trauma, at all, chemical or otherwise? I might attempt to irrigate the eye with NS, transport with both eyes closed to avoid movement to damaged eye. Why didn't she return for the second surgery? Did she follow all post-op instructions, correctly? Any signs of trauma? (periorbital or retroauricular ecchymoses, skull and facial bones intact?) Link to comment Share on other sites More sharing options...
brentoli Posted July 13, 2007 Share Posted July 13, 2007 Can we try the cincinnati stroke scale on her? I don't feel led in this direction, but I want to rule it out as well. I don't think the cataract is the sole cause. From some studying, I am leaning towards this being some sort of vascular incident. I don't have enough physiology background to really understand the specifics of what I have read however, and I don't want to try to play it off like I do. Link to comment Share on other sites More sharing options...
medic001918 Posted July 14, 2007 Share Posted July 14, 2007 I'm not going in the direction of a stroke either. Built up over a few days, cushings triad (while not always present), would most likely me more prevelant and would most likely be presenting with some other associated signs and symptoms. I'm not getting the cataract feeling. Acute glaucoma crossed my mind, but is usually a narrowing of the vision, or an encroaching darkness. That doesn't usually present with the milky description. I want to know more about the proposed surgical procedure. What was it for? Why didn't she go? Was it secondary to injury? Was that for cataracts too? Given that she has some swelling, could it be a foreign body somehow? I know that when I used to race motorcycles I would get dirt in my eyes frequently. Sometimes it caused me to have redness, irritation, photophobia (light sensitivity) and would cause some swelling, redness and tearing. Will she allow us to have a good look at her eye, and maybe under her eyelid to look for some foreign body? Could it also be ocular hypertension due to some sort of thrombus? Never thought I'd bring that up in a case or a sceanrio. But it seems like it could be possible. I believe ocular hypertension usually precedes full blown glaucoma...but I could be wrong. As far as prehospital treatment, so far it sounds like BLS. Irrigate and cover the eyes, monitor vitals and transport non-emergent. I'd like to know more though... Shane NREMT-P Link to comment Share on other sites More sharing options...
CivilDefense2002 Posted July 14, 2007 Share Posted July 14, 2007 Thought I might try one of these scenarios. Don't laugh at me too much! :shock: Seems to me to be acute angle closure glaucoma. We can see already that she's got ocular HTN from the buldging iris, plus swelling and tearing. All classic signs. The angle has been blocked or closed, and aqueous humor has and is building up. Not much I could do to treat this. Finish the H/P, V/S, maybe with some O2 via NC. Definitely start a line and draw labs for the ER. Interestingly enough, the eye patch is making the IOP worse by causing pupillary dilation. I'd remove that immediately. The optho people call acute angle closure glaucoma a true emergency, and I've heard them say we should transport emergent. However, since this has been going on for several days already, an extra two minutes delay with a safer, non-emergency transport wouldn't hurt as I see it. We'd be delayed even more if we got in an accident. More info here: http://www.emedicine.com/emerg/topic752.htm CivilDefense2002 Link to comment Share on other sites More sharing options...
brentoli Posted July 14, 2007 Share Posted July 14, 2007 More info here: http://www.emedicine.com/emerg/topic752.htm CivilDefense2002 That is actually one of the articles I read. Glad to see I wasn't shooting in the dark at least. Link to comment Share on other sites More sharing options...
brentoli Posted July 15, 2007 Share Posted July 15, 2007 Where oh where has my ER Doc gone... Link to comment Share on other sites More sharing options...
Dustdevil Posted July 15, 2007 Share Posted July 15, 2007 This is almost identical to the scenario we got in a continuing ed discussion by e-mail a couple weeks ago. Must be something going around. :? Link to comment Share on other sites More sharing options...
ERDoc Posted July 15, 2007 Author Share Posted July 15, 2007 Sorry about the delay, but this is indeed acute angle glaucoma. As someone stated, there is nothing you can do about it in the field, but it is good to recognize it. I was looking for a good picture, but 2D just does not do it justice, you need to see it in real life. The classic symptoms in this case were the red, watery eye with the iris looking like it was pressing against the cornea with a mid sized, fixed pupil. Link to comment Share on other sites More sharing options...
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