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Eye Pain & Vision Loss

UnFiNiShEd CaSe CoMe BaCk LaTeR

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History of Present Illness:

A 72-year-old female with a history of cataract surgery, macular degeneration, HTN and atrial fibrillation presents to the ED for 3 days of decreased vision in her left eye associate with eye discomfort nausea and pain behind her eye. She vomited on route here. She denies any head trauma, fall neck or back pain, shortness of breath or other complaints.

Vital Signs & Physical Exam:

Vital signs are normal except for   Physical exam is normal except for a red eye without discharge and no light perception vision in the left eye.  Eye pressure is 61 on the left and 15 on the right

Initial Differential Diagnosis: 

Relevant Test Results:

  • EKG: atrial fib, rate controlled
  • Labs: none ordered
  • Imaging: see bedside US below.

QUESTIONS:

  1. What does the case image show?  
  2. What should you do next?  
  3. Want a 1-minute consult/tutorial on this case? 
  4. Want to know what happened with this patient?

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ANSWERS:

  1. What does the case image show?  The image shows a vitreous hemorrhage.
  2. What should you do next?  Start glaucoma meds, consider reversing Eliquis.  Consult Ophtho
  3. Want a 1-minute consult/tutorial on this case?  See yellow areas from sample page below.
  4. Want to know what happened with this patient?  FFP given.  Given the duration of symptoms it was thought unlikely that the eye would recover so no PCC given due to higher risk of stroke nor mannitol given due to higher risk of intracranial bleed.  Pressure did not improve for hours.

1-Minute EM Consult on the topic for this case from the Emergency Medicine 1-minute Consult Pocketbook

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CASE CONCLUSION: Permanent vision loss from prolonged glaucoma caused by intraocular bleed.

CASE LESSONS:

  1. Always consider intraocular bleeding in a patient on thinners
  2. Always consider glaucoma with eye pain, vomiting or vision loss
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