Sudden Painful Vision Loss in ED | Acute Congestive Glaucoma Case Presentation || ||

[00:00:06]Welcome to ATCM the emergency medicine channel. Good morning sir.

[00:00:09]>> Good morning >> sir. Shall I start presenting the case sir? Here is a 60 year old male presented to ER with complaint of sudden onset painful loss of vision of right eye since today morning. Uh his right eye is red at presentation. No also complaining of headache and two to three episodes of vomiting.

[00:00:32]You straight away jump jump jump jump jump jump jump jump jump jump jump jump jump jump jump jump jump jump jump jump jump jumps to the >> no that was also the presenting complaints.

[00:00:38]>> Okay right leg >> painful >> pain painful >> vision loss >> vision loss >> yeah since today morning with associated headache and two to three episodes of vomiting >> headache vomiting.

[00:00:54]So what is your diagnosis through the presenting complaint? is what will be your >> diagnosis >> sir as it is >> painful unilateral vision loss with headache and vomiting >> all of a sudden >> it can be a optic pathology and to optic mean optic asthma >> painful no painful >> so what so what what what can be acute congestive glaucoma >> acute angle of glaucoma is your first diagnosis >> optic neuritis can also happen >> is vomiting >> optic neuropathy.

[00:01:32]>> So you're okay. All right. Continue.

[00:01:36]>> Yes sir.

[00:01:36]>> Sir in the initial 10-second assessment airway was tighten breathing uh respiratory primary service clear.

[00:01:42]>> Yes sir. Clear.

[00:01:43]>> All right.

[00:01:44]>> Uh pressure was little bit on the higher side 150 or 90.

[00:01:49]Then uh right eye pupil non reacted to light on disability face.

[00:01:56]Wi-Fi people not reacting >> then exposure there is no hypothermia as an adjun to >> left is reacting.

[00:02:07]>> Oh yeah left is reacting sir.

[00:02:11]>> You mean to say the direct light reflex?

[00:02:13]>> Yeah. Yes sir. is nonreacting in the right eye and left it is >> reacting >> is present left eye consension and direct is there but right eye there is no reflexes nonreactive >> okay >> to both direct and consension >> as an agent to primary survey uh point of care and EBG has can has been taken [clears throat] >> sir CRP September.

[00:02:49]>> But why adjunct primary survey? Primary survey is clear. So is there any point in taking other adjunct BBG and >> to look for anyia and hyperfusion for lactate elevation?

[00:03:05]>> Okay. Eskeemia primary ser it is not a life-threatening problem.

[00:03:10]>> Okay sir. There's no no problem in airway breathing circulation [clears throat] disability or exposure adjun to primary survey is not really primary service as as such it is clean you can straight away move to secondary survey take your ample history >> she also had he also had instead of headache and vomiting also so >> you suspected IC bleed >> uh something yeah that's why >> okay so in that case you should have taken straight taken city plane >> but uh the most major complaint was redness. So evaluation found out to be on further evaluation found out [snorts] to be main a major eye pathology >> that thanks to primary survey that is the only thing I see bleed is only disability disability that is a one striking striking problem and headache is there vomiting is there some vision loss is also there redness of the eye is there so I bleed is one possibility which you'd have to do a CT and roll out an IC bleed >> okay and the left >> uh left right side is the loss left.

[00:04:17]Okay. Was I taken CT?

[00:04:20]>> CT was not taken, sir.

[00:04:22]>> Okay.

[00:04:23]>> Then >> sir, sample history.

[00:04:26]So, uh here is a 60-year-old male. A known case of type2 diabetes hypertension. Previous corial grafting has been done for blood trauma to the right eye.

[00:04:35]>> Type two diabetes hypertension.

[00:04:38]>> Previous coral grafting has been done for which side?

[00:04:44]>> Right side. Right.

[00:04:46]>> Coronial grafting >> for what?

[00:04:49]>> Blunt trauma the right side.

[00:04:52]>> Okay.

[00:04:53]>> Then presented to you with >> when was that?

[00:04:56]>> Uh around 2022 and he was a recurrent followup of themology >> because his diabetic patient can have diabetic complications.

[00:05:09]>> Okay.

[00:05:10]>> Diabetic retinopathy. Catact also can help.

[00:05:13]>> Catact can be there.

[00:05:19]Hypertension is also there. Hypertensive retopathy that's also possibility.

[00:05:26]>> Okay.

[00:05:27]>> Presented uh to ER with complaint of sudden painful loss of vision since today morning.

[00:05:35]>> Okay.

[00:05:35]>> Right eye is red in color.

[00:05:38]>> You gave some analysis for the pain. Oh >> yes sir. We had been given uh PCM >> but pain is not >> so this is pain. So you'll have to mention in detail about the sorcerus >> sir it was sudden in onset progressive in nature not relieving with u uh aggravating with opening the character means uh character of the pain uh severe throbbing type of pain. So uh the pain aggravates on movement even with the movement of left eye also the pain is aggravating >> pain aggravates on opening the left eye also as the left eye is normal but on opening the left eye pain increases on right eye.

[00:06:19]>> Okay. Okay.

[00:06:22]>> No relieving factors.

[00:06:26]Um uh the right eye is red in color. There is watering of uh eye was present from right side. Uh history of two to three episodes of uh non-belious non- projectile vomiting was there. Uh no history of any trauma to the eye. No history of any flout, flashes of light or black spots seen.

[00:06:46]No history of trauma or fall.

[00:06:51]So >> why what you need is like in case of a unilateral vision loss, how should an emergency physician approach?

[00:07:00]Sir first we will look whether it is a painful or painless loss of vision.

[00:07:04]>> Okay.

[00:07:06]>> So it is >> so what are the causes of painless loss of vision?

[00:07:11]>> Central retinal arterial operation central >> CORVO CR is a sort of ocular stroke.

[00:07:18]>> Yes.

[00:07:18]>> And if you have to diagnose it early because >> because the injury time is very less.

[00:07:23]>> Yeah. Just like a stroke you have got only some 90 minutes to 4 hours >> for the treatment otherwise you'll have permanent damage >> damage to the retina. You will have to diagnose that CRO >> and in fundoscopy you'll get what cherry cherry >> cherry red spot >> cherry red spot okay then CR >> V >> Valion to macular edmaically splash tomato appearance >> okay splash tomato appearance >> stormy stormy sky appearance also >> stormy sky appearance okay we then have tooscopy anyway [snorts] then What >> retinal detachment can also present >> retinal detachment is another possibility >> vitus hemorrhage >> like a curtain it will be there >> yeah curtain falling in front of that >> vict [snorts] post detachment also >> detachment okay then >> okay then what are the causes of painful >> can be any uh trauma High ulceration glaucom >> ulcer optic nerve pathologist.

[00:08:44]>> Okay.

[00:08:47]>> Ro injury. Okay.

[00:08:51]Okay.

[00:08:53]Then this thing giant cell arritis.

[00:08:58]>> That is a possibility.

[00:09:01]Yeah, that's all.

[00:09:04]>> Okay, >> sir. Uh then how to assess uh a patient in ED with how to assess the patient clinically?

[00:09:13]The first thing we have to assess the visual activity that is from 3 m we have to put chest and start and we'll see the patient. Uh then if the patient is not able to follow that we have to do [snorts] counting fingers how many fingers he can assess. Uh if that also not possible we have um >> other history nothing history history is over.

[00:09:34]>> Yes sir.

[00:09:35]>> So you told other past history >> past history diabetes hypertension past surgical history.

[00:09:41]>> That's all. Okay.

[00:09:44]>> Okay. Other other histories are not relevant in this case this particular case.

[00:09:52]The only thing is bleed any hyper hypertens control. Yes sir. 150 or 90 >> drug history. The drug history. What all drugs he's on?

[00:10:00]>> He's on uh insulin injection and O >> any antiplate because IC bleed can occur in some antiplatlets anticoagulants.

[00:10:11]It's not there >> only on insulin injection and O and Sartin.

[00:10:18]>> Is he using any specs >> at present? No, not on specs.

[00:10:25]Okay.

[00:10:28]So without when when was the last time his vision was checked?

[00:10:34]>> 6 months back.

[00:10:36]>> Was it normal completely fine or?

[00:10:38]>> Yeah, >> cuz he had some you told he had some right eye coral.

[00:10:41]>> Coral.

[00:10:42]>> Yeah sir. A grafting has been done for that patient. He's on regular followup.

[00:10:46]It was normally >> no other abnormality. And he was on some eye drops also.

[00:10:53]>> What eye drops? Uh theolone glaucoma was >> block means I previous history of glaucoma was there beta block >> okay so then again your diagnosis points towards glcom so uh we'll check the visual acity on examination >> then your on examination >> yeah examination first >> the examination >> first visual activity examination Visuality. Uh >> what are the things you you should examine right?

[00:11:30]>> Visuality reflexes.

[00:11:32]Then >> first of all your external examination of other things are all specialized to the function. External examination you'll have to see compared to the normal eye how it appears.

[00:11:46]>> Okay. That has to be how was it?

[00:11:49]External eye was red. Watering was red.

[00:11:52]>> What about eyelid? Like >> one by one you have to check >> just like you do an of themology examination for ambiguous level. You have to check one by one the eyelids, cornea, pupils.

[00:12:07]>> Okay.

[00:12:08]>> Okay.

[00:12:10]>> Eyelids and all was normal only sir. You >> have to go down and examine up.

[00:12:16]>> All parts you have to examine. Okay.

[00:12:18]Right?

[00:12:19]>> Then uh the conjective was red with watering of ice was present >> not able to >> then conjunctivitis is another possibility. If vision loss wasn't there, >> vision loss wasn't there. Ponttoitis then >> then sever.

[00:12:37]>> What about eyelashes?

[00:12:41]>> Okay. Then cornea just I vision eye redness. Coral redness is there. Okay.

[00:12:52]>> That's all right. Yes sir.

[00:12:54]>> No protrusion of eye. No protrusion.

[00:12:57]>> [clears throat] >> Okay.

[00:12:59]>> Then visuality assessment.

[00:13:02]>> Okay.

[00:13:03]>> So >> they're going into depth because it is a unilateral uh vision loss. Where could be the possible problem be like >> anterior to optic asma? It can be optic nerve.

[00:13:15]>> Yeah. It should be anterior to the optic asma. If the injury was in at the optic asthma, if I cut the optic asma, where would be the vision must be like >> boral >> bmporal immopia? Okay. Okay. So if I go posteriorly to the optic asma the optic tract the lateral geniculate body the optic radiation then then other unilateral is not a thing because you have got a crossing right and the optic kasma of both eyes. So unilateral complete vision loss means it should be proximal to the optic charisma. Some problem should be proximal.

[00:13:59]Okay. So optic neuritis is one possibility there is if you cut the optic >> no that is >> can be lost then if there is a problem with the retina detachment like my attachment post detachment any flus or any >> so visual activity assessment uh here in this case right I was non reactive to light Left eye was um 3x3 was there >> nonreactive to light >> that mean direct >> direct and consensual >> visual 6x6 >> uh no sir he's not only know not able to appreciate anything from right eye >> left eye >> left eye is fine >> 6x6 >> yeah sir >> then uh in ER we'll look at three 3 m distance we'll check accent >> so it was 3x3 >> no perception of Right also >> I know to the right eye no perception of light >> tonome tonometry we have done for IOP was our DDS one of the major DDS was acute congestive loma we directly went to uh find out the intraocular pressure by tonometry. So the right eye pressure was around 22.

[00:15:20]>> What is the normal IOP?

[00:15:22]>> 10 to 21 mm >> HG 22 means is it? Uh yeah 22 is not significant. Uh actually dial variations can happen 5 to 10 but it is more than the normal IO but >> it should be nor more than 40 right.

[00:15:39]>> What is normal more than 21 sir? No no no to call it acute angle cross glaucom and >> sir glaucom normal tension glaucoma can also happen sir with visual field effects and yes features. Yes sir. All right. Okay. Then >> uh then uh fondoscopy has been done by our ofthmology people and all.

[00:16:07]>> That's all. Then you have to from your point you have to find out whether there's a problem with the >> as we don't have a fosscope available.

[00:16:15]>> No the swinging flashlight test >> that uh yes I did already that there is no >> RD there is an optic nerve nerve pathology.

[00:16:25]>> Yeah. relative to a pupilary defect, right?

[00:16:28]>> How do you do it? The swinging flashlight.

[00:16:34]>> So, we'll uh take a >> You want to know the whether the nerve is the problem? How do you do it?

[00:16:41]>> In a dim you switch off the light here.

[00:16:44]>> Yes sir. And then take the torch not in completely dark room slightly slight should be there and then ask to ask the patient to look at distant object and then you can use a steady light >> light source and then you can shine it to one >> eye >> then >> and then quickly you can >> flash it to the other eye. Usually uh if I shine light to one eye the other >> pupil should people should conflict.

[00:17:13]M >> but if you do the if you do it and if the pupil doesn't constrict like that it means there is an aerent pupilary defect that means the other eye yeah there is a problem in the optic nerve of the other eye okay then your diagnos here it was fine right >> it was fine I repeat this one right eye is not reactive >> not reactive so could be a problem in the >> nar can be a problem >> right Right was not at all.

[00:17:48]>> Angle right now your diagnosis will be like acute angle glaucoma and >> optic neuritis.

[00:17:53]>> Optic neuritis.

[00:17:56]>> Okay.

[00:17:59]>> Then sir uh then we uh manage the pain and all in system examination was normal in every all aspect all systems.

[00:18:09]>> Anything more to look What is up and reference pathway of listening?

[00:18:17]>> Uh vision sir is first >> up front nerve.

[00:18:26]>> Uh sir first light regimen then from optic nerve. No, not like that.

[00:18:34]>> Which is a >> uh a >> optic of nerve P1 of mandibular nerve.

[00:18:48][clears throat] >> Okay.

[00:18:51]Should you should know the pathway correctly. [clears throat] >> Just know where what happens. Nobody will be able to appreciate. So from an emergency perspective the thing is identify whether the patient is having a [clears throat] what painful painless vision loss or a painful vision loss >> and you should know the DDS and subsequently what >> man ED management >> ED management then importance of finding out whether it is a CR or >> a CR >> because it's a store kind of the CRVO acute eskeemic optic >> neuropathy right detachment which is hemorrhage >> okay or it is a painful acid glaucoma optic neuritis corial ulcer >> endothermititis Right.

[00:19:56]>> Okay.

[00:19:58]>> Continue >> sir. Systemic exam mission wise everything looks normal only sir.

[00:20:03]Patient is conscious oriented. All systems are normal. No uh significant uh deviation was there.

[00:20:11]>> So you informed the >> concern department.

[00:20:13]>> Concern department. So what did they do?

[00:20:15]What what did they >> uh they had they uh took the patient for pendoscopy >> and uh found out to be acute congestive glaucoma >> and uh they managed >> that's all new >> then you can also do a this thing what about the CBC CRP yes sir >> sir uh everything was looks normal only sir with the gel arritis and all this thing will be elevated yeah okay then you then you'll have to give Steroids >> steroids >> hydro >> steroids >> has to be then you have got the focus >> point of your ultrasound using the vascular probe you can keep here and you can find out where the problem is is it a problem in the >> retina retina there is a vious hemorrhage and all these things you can see and see it for yourself.

[00:21:14]That's all.

[00:21:14]>> That's also something more.

[00:21:23]Okay. Thank you.