Ophthalmology
Acute angle closure glaucoma
➢ Also called acute glaucoma or narrow-angle glaucoma
➢ Obstructed anterior chamber angle → an impairment of aqueous outflow → rise in IOP
Predisposing factors
• Hypermetropia (farsightedness) Myopia is a Rf for:
• Pupillary dilatation • Cataract
• Retinal detachment
Presentation
• Open angle glaucoma
• Red, severely painful eye with a semi-dilated non-reacting pupil
• Headaches and decreased visual acuity are common
• Symptoms worsen with mydriasis (e.g. watching TV in a dark room, applying topical mydriatics)
• Colored haloes around lights may be seen by patients
• Palpation of the globe will reveal it to be hard
• Corneal edema results in dull or hazy cornea
• Systemic upset may be seen, such as nausea and vomiting and even abdominal pain
- The acute attack is usually unilateral; however, long-term management will be to both eyes
- ICP can lead to optic disc papilledema
Investigation
• Ocular tonometry → IOP >30 mmHg (normal IOP = 15-20)
Management
Medical
• Initial medical treatment typically involves all topical glaucoma medications that are not contra-indicated in
the patient, together with intravenous acetazolamide
• Topical agents include
- Beta-blockers - e.g. timolol, cautioned in asthma
- Steroids - prednisolone 15 every 15 minutes for an hour, then hourly
- Pilocarpine 1-2% → a miotic drug to constrict the pupil and open the angle
- Acetazolamide is given intravenously (500 mg over 10 minutes) and a further 250 mg slow-release tablet
after one hour
- Offer systemic analgesia ± antiemetics
• This should tide the patient over until they are able to be seen by a duty ophthalmologist who will assess the
situation at short intervals until the acute attack is broken
• These treatments may be repeated depending on the IOP response and a combination of these medications
will be given to the patient on discharge
• The patient will remain under close observation (e.g. daily clinic reviews or as an inpatient). Subsequent
treatment is aimed at specific mechanism of closure
Surgical
• Peripheral iridotomy (PI)
- This refers to (usually two) holes made in each iris with a laser
- This is to provide a free-flow transit passage for the aqueous
- Both eyes are treated, as the fellow eye will be predisposed to an AAC attack too
- This procedure can usually be carried out within a week of the acute attack, once corneal edema has
cleared enough to allow a good view of the iris
• Surgical iridectomy
- This is carried out where PI is not possible. It is a less favored option, as it is more invasive and therefore
more prone to complications
PLABverse - 1
, Ophthalmology
Anterior uveitis
➢ Also referred to as “iritis” or “iridocyclitis”. It is one of the important differentials of a red eye
Features
Acute anterior uveitis
• Progressive (over a few hours/days) unilateral, painful red eye
• Reduced visual acuity
• Photophobia
• Pupil → abnormal shape/size
- Small pupil, initially from iris spasm
- Later it may be irregular or dilate irregularly due to adhesions
between lens and iris
• Excess tear production
• Characteristic sign → cells in the aqueous humour seen on slit-lamp
- Aqueous humour is cloudy, giving the appearance of a 'flare'. This appears rather like a shaft of light
shining through a darkened, smoky room
- Anterior chamber flare is due to inflamed vessels leaking protein. Due to the cloudiness, as the slit-
lamp beam of light is shone through, the beam disperses hence the term flare
Chronic anterior uveitis
• Presents as recurrent episodes, with less acute symptoms
• Patients may find that one symptom predominates (this tends to be blurred vision)
• Most common cause of chronic anterior uveitis → Sarcoidosis
Associated conditions
• Ankylosing spondylitis • RA → Sclera
• AS → Uveitis
• Reactive arthritis
• IBD
Management
• Prednisolone eye drops → to reduce inflammation
• Cyclopentolate → to prevent adhesions between lens and iris by keep pupil dilated
- Intermediate uveitis = pars planitis = viritis
- Posterior uveitis = chorioretinitis
- Most common form of uveitis → Anterior uveitis
PLABverse - 2
Acute angle closure glaucoma
➢ Also called acute glaucoma or narrow-angle glaucoma
➢ Obstructed anterior chamber angle → an impairment of aqueous outflow → rise in IOP
Predisposing factors
• Hypermetropia (farsightedness) Myopia is a Rf for:
• Pupillary dilatation • Cataract
• Retinal detachment
Presentation
• Open angle glaucoma
• Red, severely painful eye with a semi-dilated non-reacting pupil
• Headaches and decreased visual acuity are common
• Symptoms worsen with mydriasis (e.g. watching TV in a dark room, applying topical mydriatics)
• Colored haloes around lights may be seen by patients
• Palpation of the globe will reveal it to be hard
• Corneal edema results in dull or hazy cornea
• Systemic upset may be seen, such as nausea and vomiting and even abdominal pain
- The acute attack is usually unilateral; however, long-term management will be to both eyes
- ICP can lead to optic disc papilledema
Investigation
• Ocular tonometry → IOP >30 mmHg (normal IOP = 15-20)
Management
Medical
• Initial medical treatment typically involves all topical glaucoma medications that are not contra-indicated in
the patient, together with intravenous acetazolamide
• Topical agents include
- Beta-blockers - e.g. timolol, cautioned in asthma
- Steroids - prednisolone 15 every 15 minutes for an hour, then hourly
- Pilocarpine 1-2% → a miotic drug to constrict the pupil and open the angle
- Acetazolamide is given intravenously (500 mg over 10 minutes) and a further 250 mg slow-release tablet
after one hour
- Offer systemic analgesia ± antiemetics
• This should tide the patient over until they are able to be seen by a duty ophthalmologist who will assess the
situation at short intervals until the acute attack is broken
• These treatments may be repeated depending on the IOP response and a combination of these medications
will be given to the patient on discharge
• The patient will remain under close observation (e.g. daily clinic reviews or as an inpatient). Subsequent
treatment is aimed at specific mechanism of closure
Surgical
• Peripheral iridotomy (PI)
- This refers to (usually two) holes made in each iris with a laser
- This is to provide a free-flow transit passage for the aqueous
- Both eyes are treated, as the fellow eye will be predisposed to an AAC attack too
- This procedure can usually be carried out within a week of the acute attack, once corneal edema has
cleared enough to allow a good view of the iris
• Surgical iridectomy
- This is carried out where PI is not possible. It is a less favored option, as it is more invasive and therefore
more prone to complications
PLABverse - 1
, Ophthalmology
Anterior uveitis
➢ Also referred to as “iritis” or “iridocyclitis”. It is one of the important differentials of a red eye
Features
Acute anterior uveitis
• Progressive (over a few hours/days) unilateral, painful red eye
• Reduced visual acuity
• Photophobia
• Pupil → abnormal shape/size
- Small pupil, initially from iris spasm
- Later it may be irregular or dilate irregularly due to adhesions
between lens and iris
• Excess tear production
• Characteristic sign → cells in the aqueous humour seen on slit-lamp
- Aqueous humour is cloudy, giving the appearance of a 'flare'. This appears rather like a shaft of light
shining through a darkened, smoky room
- Anterior chamber flare is due to inflamed vessels leaking protein. Due to the cloudiness, as the slit-
lamp beam of light is shone through, the beam disperses hence the term flare
Chronic anterior uveitis
• Presents as recurrent episodes, with less acute symptoms
• Patients may find that one symptom predominates (this tends to be blurred vision)
• Most common cause of chronic anterior uveitis → Sarcoidosis
Associated conditions
• Ankylosing spondylitis • RA → Sclera
• AS → Uveitis
• Reactive arthritis
• IBD
Management
• Prednisolone eye drops → to reduce inflammation
• Cyclopentolate → to prevent adhesions between lens and iris by keep pupil dilated
- Intermediate uveitis = pars planitis = viritis
- Posterior uveitis = chorioretinitis
- Most common form of uveitis → Anterior uveitis
PLABverse - 2
