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Iridotomy
38%
8/21
Methylprednisolone
5%
1/21
Pilocarpine drops
Retinal reattachment
48%
10/21
Timolol drops
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This patient is presenting with acute eye pain after spending time in the darkness as well as is seeing visual halos, has impaired vision, and has a fixed and dilated pupil which is concerning for acute angle-closure glaucoma. Definitive treatment is a laser peripheral iridotomy. Acute angle-closure glaucoma occurs when the natural drainage system for aqueous outflow is obstructed. The angle refers to the area between the iris and cornea, through which fluid must flow to escape via the trabecular meshwork. When this angle is closed, intraocular pressure rises rapidly, causing compression of the vessels that oxygenate the retina. In a short time, these cells may become ischemic resulting in retinal ganglion cell death and optic nerve atrophy. Patients present with ocular pain, halos, a red eye, elevated intraocular pressures, decreased vision, and a fixed, dilated pupil. Initial medical treatment involves timolol, acetazolamide, dorzolamide, brimonidine, and pilocarpine. Definitive treatment is via laser peripheral iridotomy which involves opening a small hole in the iris with a laser which can re-establish proper aqueous outflow. Figure A depicts the classic appearance of acute angle-closure glaucoma with a fixed, dilated pupil. Incorrect Answers: Answer 2: Methylprednisolone is a potent IV steroid which can be given for a flare of multiple sclerosis which may present with optic neuritis. Optic neuritis presents with sudden-onset, painful vision loss in a young woman with other neurologic complaints (such as paresthesias or weakness). Answer 3: Pilocarpine drops act on the muscarinic receptors and cause miosis which opens the angle; however, this is not definitive treatment of this condition. Answer 4: Retinal reattachment is indicated in the management of retinal detachment which presents with vision loss with a "curtain coming down" over the visual field. Ultrasound can further characterize the detached retina. Answer 5: Timolol drops block beta-receptors, reduce aqueous humor production, and are appropriate initial medical treatment but are not definitive therapy. Bullet Summary: Iridotomy is the definitive treatment of acute angle-closure glaucoma.
4.2
(5)
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