Rosen & Barkin's 5-Minute Emergency Medicine Consult (301 page)

• No specific interventions need occur prior to arrival at the hospital in regard to the eye:
  
  • Pain control may be necessary
    
  • In traumatic etiologies, stabilize other injuries
    

• Initiate steps to lower intraocular pressure in acute closed-angle glaucoma:
  
  • Address other effects of trauma if this was the etiology
    
  • Discontinue inciting medication when involved
    

• Primary open-angle glaucoma:
  
  • Recognition and prompt ophthalmologic referral
    
  • Patients maintained on topical β-blockers or prostaglandin analogs to decrease IOP
    
• Primary angle-closure glaucoma (ophthalmologic emergency):
  
  • Intraocular pressure reduction:
    
    • Topical β-blocker, timolol maleate, to decrease aqueous humor production
      
    • Topical α
      ₂
      -agonist, apraclonidine, to decrease aqueous humor production
      
    • Carbonic anhydrase inhibitor, acetazolamide, for reduction of formation of aqueous humor
      
    • Hyperosmotic agent, mannitol, to draw aqueous humor from vitreous cavity into blood (indicated for severe attacks).
      
  • Movement of iris away from trabecular meshwork:
    
    • Topical parasympathomimetic, pilocarpine hydrochloride, to constrict pupil once intraocular pressure is <40 mm Hg
      
  • Reduction of inflammation:
    
    • Topical corticosteroid, prednisolone acetate
      
  • Emergent ophthalmology consultation for possible definitive surgical treatment, laser iridectomy, if no improvement with medical management
    
  • Adequate narcotic analgesia and antiemetics as needed
    

• Acetazolamide: 500 mg IV or PO
  
• Mannitol 20%: 1–2 g/kg IV over 30–60 min
  
• Pilocarpine hydrochloride 1–2% solution: 1 drop q15–30min until pupillary constriction occurs, then 1 drop q2–3h
  
• Prednisolone acetate 1% solution: 1 drop q15–30min for total of 4 doses
  

• β-Agonists:
  
  • Timolol maleate 0.25 or 0.5%:
    
    • 1 drop to affected eye BID
      
  • Levobunolol 0.25 or 0.5%:
    
    • 1 drop to affected eye BID
      
  • Carteolol HCL 1%:
    
    • 1 drop to affected eye BID
      
  • Betaxolol 0.25 or 0.5%:
    
    • 1–2 drop(s) to affected eye BID
      

• Adrenergic agonists:
  
  • Apraclonidine 0.5%, 1%:
    
    • 1–2 drop(s) to affected eye BID
      
  • Brimonidine:
    
    • 1 drop to affected eye TID
      
• Carbonic anhydrase inhibitors:
  
  • Acetazolamide:
    
    • 125–250 mg PO QID
      
  • Methazolamide:
    
    • 50–100 mg PO BID
      
  • Dorzolamide HCl 2%:
    
    • 1 drop in affected eye TID
      
  • Brinzolamide:
    
    • 1 drop to affected eye TID
      
• Prostaglandin analogs:
  
  • Latanoprost:
    
    • 1 drop in affected eye QHS
      
  • Bimatoprost 0.03%:
    
    • 1 drop in affected eye QHS
      
  • Travoprost:
    
    • 1 drop in affected eye QHS
      
  • Unoprostone:
    
    • 1 drop to affected eye BID
      

• Prostaglandin analogs have become standard of care for open-angle glaucoma due to an improved side-effect profile
  
• Due to cost, topical β-blockers are often still used primarily
  

FOLLOW-UP

• Severe pain, nausea, or vomiting
  
• Patients receiving parenteral medications should be observed for side effects.
  
• Patients without improvement of symptoms or intraocular pressures should be admitted for continued monitoring of intraocular pressure, medical treatment, and possible definitive surgical management:
  
  • Laser intervention is more likely than operative
    

Patients with minor symptoms and significant improvement of intraocular pressure may be safely discharged once seen by ophthalmology and with close, <24-hr follow-up.

If no ophthalmologist is available, treatment should be initiated and patient transferred to nearest hospital with ophthalmologic consultation.

• Open-angle glaucoma patients need urgent ophthalmology follow-up to optimize medical management
  
• Closed-angle glaucoma patients need immediate intervention
  

• Increased IOP can cause vascular insufficiency and with delayed treatment vision loss can be permanent
  
• Eye pain/headache can be associated with severe abdominal pain—do not ignore the eye and miss the diagnosis
  
• Patients maintained on topical β-blockers for open-angle glaucoma may present with systemic side effects including orthostatic hypotension, bradycardia, or syncope
  

• Chew P, Sng C, Aquino MC, et al. Surgical treatment of angle-closure glaucoma.
  Dev Ophthalmol.
  2012;50:137–145.
  
• Dargin JM, Lowenstein RA. The painful eye.
  Emerg Med Clin North Am
  . 2008;26(1):199–216.
  
• Marx JA, Hockberger RS, Walls RM, et al.
  Rosen’s Emergency Medicine: Concepts and Clinical Practice
  . 7th ed. St. Louis, MO: Mosby; 2010.
  
• Müskens RP, Wolfs RC, Witteman JC, et al. Topical beta-blockers and mortality.
  Ophthalmology
  . 2008;115(11):2037–2043.
  
• Nongpiur ME, Ku JY, Aung T. Angle closure glaucoma: A mechanistic review.
  Curr Opin Ophthalmol.
  2011;22(2):96–101.
  
• Tse DM, Titchener AG, Sarkies N, et al. Acute angle closure glaucoma following head and orbital trauma.
  Emerg Med J.
  2009;26(12):913.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Red Eye
  
• Visual Loss
  

CODES

• 365.9 Unspecified glaucoma
  
• 365.11 Primary open angle glaucoma
  
• 365.22 Acute angle-closure glaucoma
  

BASICS

• A full-thickness corneal or scleral injury owing totrauma
  
• Blunt trauma/globe rupture:
  
  • Causes an abrupt rise in intraocular pressure diffusely
    
  • Subsequent rupture of the eye either opposite the point of impact or at the weakest points:
    
    • Extraocular muscle insertion
      
    • Corneoscleral junction
      
    • Limbus, where the sclera is thinnest
      
• Penetrating injury/globe laceration:
  
  • Occurs with sharp objects or projectiles injuring the sclera or anterior eye directly
    
  • Most commonly anterior—the bony orbit protects the globe laterally and posteriorly
    
  • Posterior injury can occur with fracture of the bony orbit or with penetrating injuries of the eyelid or eyebrow.
    
• Prognosis worse with:
  
  • Larger lacerations
    
  • Injury posterior to the rectus insertion
    
  • Blunt injury
    
  • Intraocular foreign body, especially if made of organic material
    
  • Vitreous extrusion
    
  • Lens damage
    
  • Hyphema
    
  • Retinal detachment
    
  • Poor visual acuity at presentation
    
  • Afferent pupillary defect
    
  • Increased time to OR
    

• Falls, impact injuries
  
• Sport-related injuries (e.g., elbow, ball impacts, arrows, game controllers, etc.)
  
• Indirect concussive injuries (explosions)
  
• Sharp instrument/stabbing injuries, accidental or intentional
  
• Projectile injuries (industrial, firearms, BB pellets, blast explosion shrapnel—glass, etc.)
  

DIAGNOSIS