Astute assessment leads to timely treatment.

Karen Smith*, a 60-year-old woman with a history of hypertension, hypercholester­ol­emia, and noninsulin-dependent diabetes, arrives at the hospital for an outpatient screening col­on­oscopy. Asa, an endoscopy nurse, completes Ms. Smith’s intake nursing assessment, including vital signs: temperature 98.4° F (36.9° C), heart rate 74 beats per minute, respiratory rate 18 breaths per minute, blood pressure 128/82 mmHg, and oxygen saturation 99% on room air.

While awaiting her colonoscopy, Ms. Smith develops severe right periocular pain, decreased vision, and nausea. Ms. Smith rings her call light to notify Asa. She reports that she sees halos around lights, her right eye pain is 10/10, and the pain feels sharp, stabbing, and constant. While speaking with Asa, Ms. Smith vomits a large amount of non-bloody emesis.

Taking action

During his assessment of Ms. Smith, Asa identifies a fixed midpoint dilated right pupil and conjunctival injection. He calls the rapid response team and the on-call ophthalmology resident. Asa administers 4 mg of I.V. ondansetron as ordered by the resident. Using a slit-lamp, the resident identifies a narrow right angle and marked conjunctival injection. The intraocular pressure in Ms. Smith’s right eye is 65 mmHg; a gonioscopy examination reveals acute closure of the angle between the iris and cornea, consistent with acute angle-closure glaucoma (AACG). Examination of Ms. Smith’s left eye is unremarkable.

Outcome

The ophthalmology resident orders STAT 500 mg I.V. acetazolamide; 0.5% timolol maleate, one drop in the right eye; and 1% apraclonidine, one drop in the right eye. Asa closely monitors Ms. Smith’s intraocular pressures; when they fall below 40 mm Hg, the ophthalmology resident administers 2% pilocarpine, 1 drop every 15 minutes for two doses in the right eye. Ms. Smith requires a laser peripheral iridotomy later that day. After 24 hours of inpatient intraocular pressure monitoring, she’s discharged home with close primary care and ophthalmology follow-up.

Education and follow up

AACG, an ocular emergency, can result in blindness if not identified and treated emergently. Aqueous humor outflow obstruction results in a sudden increase in intraocular pressure. The incidence of AACG is 2 to 4 cases per 100,000 people. It’s most common in women, individuals between ages 55 and 65, and those with a family history of glaucoma.

Patients typically present with ocular pain, headache, blurred vision, decreased visual acuity, nausea, vomiting, and seeing halos around lights. Definitive diagnosis requires a goni­oscopy exam; slit lamp examination aids assessment of the anterior segment. Patients require ongoing intraocular monitoring. Treatment aims to rapidly reduce intraocular pressure by blocking aqueous humor production and increasing aqueous humor outflow. Approximately 50% of patients with AACG will develop the condition in the opposite eye within 5 to 10 years.

In Ms. Smith’s case, Asa’s astute assessment facilitated timely implementation of an evidence-based treatment plan.

*Names are fictitious.

Aaron M. Sebach is dean of the College of Health Professions and Natural Sciences at Wilmington University in New Castle, Delaware, and a nurse practitioner at TidalHealth Peninsula Regional in Salisbury, Maryland.

American Nurse Journal. 2024; 19(7). Doi: 10.51256/ANJ072442

References

Flores-Sánchz BC, Tatham AJ. Acute angle closure glaucoma. Br J Hosp Med. 2019;80(12):C174-9. doi:10.12968/hmed.2019.80.12.C174

Khazaeni B, Zeppieri M, Khazaeni L. Acute angle-closure glaucoma. StatPearls. November 26, 2023. bit.ly/3K9xtop

Salim S, Aref AA, Moore DB, Tripathy K, Giaconi J. Primary vs. secondary angle closure glaucoma. EyeWiki. April 1, 2024. eyewiki.aao.org/Primary_vs._Secondary_Angle_Closure_Glaucoma

Wetarini K, Purnama Dewi NMR, Widya Mahayani NM. Acute angle closure glaucoma: Management in acute attack setting. Bali Med J. 2020;9(1):386-9. doi:10.15562/bmj.v9i1.1659

Key words: eye disease, glaucoma, ocular emergency