This is paper will be presenting a Professional Qualifying Portfolio (PQP), and will analyze a case of the patient. In the discussion section we will be discussing the case and then will be dispensing a ophthalmic lenses with justifications. The case will also be discussing what kinds of measures those have to be taken in order to justify the lenses that are recommended.
Patient: A 51 year-old African American female presents with a sudden onset of right eye pain, severe headache, blurred vision, nausea, and vomiting.
History: The patient also reports seeing rainbow colored halos around lights. These symptoms began 2 hours ago without any inciting event. The patient was watching television when the symptoms began. There is no history of trauma, flashing lights, curtains, metamorphopsia or diplopia.
Past Ocular History:
No surgeries, laser, injection or other treatment
Past Medical History:
Degenerative disc disease (low back)
Past Family Ocular History:
Father: Chronic primary angle closure glaucoma
No history of macular degeneration, retinal detachment, blindness, or autoimmune disorders
30 pack year smoking history
Drinks alcohol on occasion
No illicit drug use
Vicodin prn (uses it about 1 day/month when back pain worsens)
I proceeded with the contact lens fitting using a plateau gas permeable contact lens (my own design).
Visual Acuity (cc)
Extraocular Movements: Intact
Right pupil mildly dilated, sluggishly responsive to light. Left normal
Confrontational visual fields: Normal OU
OD: Blurred throughout
Lids and Lashes: Normal OU
Conjunctiva/Sclera: Injected conjunctiva OD, Normal OS
Cornea: Normal OS, OD demonstrates corneal edema
Anterior Chamber - Shallow anterior chamber OD, normal depth OS,
Iris: Iris appears pushed forward OD, normal OS
Lens: Normal OU
Anterior Vitreous - Normal OU
Gonioscopy: Closed angle right eye, demonstrating iris bombe (bulging of the peripheral iris). Left eye demonstrates a narrow angle, but no apparent obstruction of the trabecular meshwork.
Dilated Fundus Examination:
OD: Hazy view through edematous cornea, CDR (cup to disc ratio) 0.3, no AV nicking, macula normal, periphery normal with no signs of retinal breaks or detachments.
OS: CDR0.3, no AV nicking, macula normal, periphery normal with no signs of retinal breaks or detachments.
Discussion and Conclusion
Normal Intraocular pressure in adults usually ranges between about 10 and 21. Acute angle closure glaucoma can cause pressures to rise very high, as seen in this patient. Angle closure is best observed using a goniolens (or gonioscope) that allows the viewer to see into the angle of the eye that cannot be done with a traditional slit lamp examination.
Acute angle closure glaucoma occurs when there is a relatively sudden blockage of the trabecular meshwork by the anterior bulging of the peripheral iris. This may occur initially with pupillary block (where the lens presses up against the iris, decreasing aqueous humor flow into the anterior chamber) resulting in increased intraocular pressure in the posterior chamber, creating a pressure gradient that subsequently presses the iris anteriorly and causes it to block the angle. Pupillary block is greatest when the iris is in a mid-dilated state. When the pupil dilates the iris bunches up on itself and makes pupillary block ...