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A 65-year-old presents with acute eye pain, nausea, and halos around lights. IOP is 54 mmHg with a mid-dilated pupil. What is the next step?
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A 58-year-old patient with type 2 diabetes presents for routine eye examination. Fundoscopic exam reveals dot-blot hemorrhages and hard exudates. Which finding would indicate the need for immediate referral?
Correct! Neovascularization of the disc indicates proliferative diabetic retinopathy, requiring urgent referral.
A 65-year-old presents with acute eye pain and halos. IOP is 54 mmHg. Next step?
Explanation
The correct answer is A. Acute angle-closure glaucoma is an emergency requiring immediate IOP reduction. IV mannitol provides rapid osmotic diuresis while topical timolol reduces aqueous production.
Answer B is incorrect. Laser iridotomy is definitive treatment but not first-line in acute attack—must lower IOP medically first.
Answer C is incorrect. Pilocarpine is ineffective when IOP >40-50 mmHg due to iris sphincter ischemia; use only after IOP lowered.
Answer D is incorrect. Never observe acute angle-closure—this is an ophthalmic emergency requiring immediate intervention.
Key Concept
Acute angle-closure = emergency → IV mannitol + timolol first → pilocarpine after IOP drops → laser PI definitive
Acute Angle-Closure Glaucoma
• Mid-dilated pupil is classic sign
• IOP reduction is first priority
• IV mannitol for rapid osmotic diuresis
• Topical timolol reduces aqueous production
• Pilocarpine after IOP lowered to open angle
• Timing of laser iridotomy vs medical tx
• Medical vs surgical management sequence
• When to use vs avoid pilocarpine
• Fellow eye prophylaxis—40-80% attack in 5 yrs
• Never dilate a shallow anterior chamber
• Laser PI is definitive, not medical therapy
Acute Angle-Closure Glaucoma
Clinical Presentation
- •Severe eye pain, headache, nausea/vomiting
- •Mid-dilated, fixed pupil; corneal edema
- •IOP typically > 40-50 mmHg
Diagnostic Approach
- •Gonioscopy: closed or occludable angles
- •AS-OCT for angle assessment
Management
- •IV mannitol 1-2 g/kg + topical timolol
- •Topical pilocarpine 1-2% after IOP lowered
- •Laser peripheral iridotomy (definitive)
Prognosis
- •Good if treated within 24-48 hours
- •Risk of chronic glaucoma if delayed
Complications
- •Permanent vision loss, optic nerve damage
- •Fellow eye attack (40-80% within 5 years)
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