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Chapter 37. The Eye & Ocular Adnexa

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A 61-year-old Caucasian woman presents with sudden-onset right-sided head pain, right eye redness, and blurred vision. Examination of the right eye is difficult due to the patient’s nausea and vomiting, but reveals visual acuity of 20/400, a mid-dilated, unreactive pupil, a hazy cornea, and an intraocular pressure of 57. What is the best course of action at this time?

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A. Obtain an immediate head CT to rule out orbital abscess.

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B. Arrange for follow-up with an ophthalmologist within the next 1-2 weeks.

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C. Medically manage the patient’s pain and nausea and arrange an urgent ophthalmology consult.

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D. Start the patient on oral acyclovir as this is likely herpes simplex-induced uveitis

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C. Medically manage the patient’s pain and nausea and arrange an urgent ophthalmology consult. Sudden onset of severe unilateral eye pain with decreased visual acuity, a dilated, unreactive pupil, hazy cornea, and elevated intraocular pressure is the classic presentation of acute angle-closure glaucoma. This is a vision threatening condition that must be managed urgently. It is necessary to treat the patient’s pain and nausea and lower the patient’s intraocular pressure with topical, oral, and IV medications; however, definitive treatment consists of performing a peripheral iridotomy.

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A 42-year-old man with a history of chronic sinusitis presents with worsening left eyelid swelling over the preceding 3 days and intermittent double vision for the past 8 hours. Examination reveals swollen, red, and warm left eyelids. Visual acuity is 20/20 in both eyes and pupillary reactions are normal; however, extraocular motility is limited on lateral gaze in the left eye. What is the best course of action at this time?

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A. Start the patient on a course of oral antibiotics.

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B. Arrange for an outpatient CT scan and endocrine follow-up as this is likely thyroid ophthalmopathy.

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C. Obtain a maxillofacial CT scan and start on IV antibiotics.

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D. Start the patient on a course of valacyclovir 1000 mg three times daily.

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C. Obtain a maxillofacial CT scan and start on IV antibiotics. Acute onset of eyelid swelling with the additional signs of eyelid warmth and redness is highly suggestive of an infectious process. Double vision and limitation of extraocular movement on the affected side indicates that there is orbital involvement. Imaging is indicated to rule out abscess formation and IV antibiotics should be initiated. Oral antibiotics would be appropriate for a preseptal cellulitis; however, there are signs of orbital involvement in this case. Thyroid ophthalmopathy is a common cause of chronic, ...

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