Acute Angle-Closure Suspect at Closing Time

The presentation is consistent with acute angle closure until proven otherwise: sudden unilateral pain, nausea, blurred vision, halos, high intraocular pressure, corneal haze, a shallow chamber, and a fixed mid-dilated pupil. This is an ophthalmic emergency. The priority is to lower pressure and arrange same-day definitive care, not to perform a routine workup or send the patient home with drops. The optometrist should call the ophthalmologist or emergency department ahead, describe the findings and pressure, and arrange urgent transfer. If the optometrist has appropriate topical medications and is permitted to use them, lowering intraocular pressure while arranging transfer is reasonable. The optometrist should not attempt laser peripheral iridotomy or any surgical intervention. Because the patient is nauseated and drove herself, the optometrist should arrange safe transport rather than let her drive after treatment or with acute symptoms. The record should note the time of recognition and transfer.

The optometrist should use only agents within DC optometric prescriptive authority and should check the current Board rules or formulary rather than assume that oral acetazolamide is permitted. Topical timolol may be used if there is no contraindication such as reactive airway disease or bradycardia; the optometrist should review the history and pulse. Pilocarpine may be considered, but it is less reliable when the iris is ischemic and the pressure is very high, and it can worsen the examination if used indiscriminately. If oral acetazolamide is within scope, the optometrist should screen for sulfonamide allergy, renal issues, and other contraindications; if it is not within scope, the optometrist should not administer it and should rely on permitted topical therapy and urgent referral. The key is to avoid both under-treatment and practicing outside scope. The optometrist should document the rationale for each medication, the consent discussion, and the response. Definitive treatment remains the ophthalmologist's responsibility.

The record should include the time of arrival, symptoms, visual acuity, intraocular pressure in both eyes, slit-lamp findings, medications given with doses and times, allergies, systemic history, and the differential diagnosis. The optometrist should document the call to the ophthalmologist or emergency department, the person spoken to, the time, the transfer plan, and the patient's transportation. The patient should receive written instructions to go directly to the arranged facility and not to drive herself. The optometrist should send a referral summary with the findings and treatment given. Follow-up should be coordinated with the receiving ophthalmologist, and the optometrist should not assume the patient improved simply because the pressure dropped temporarily. If the patient refuses transfer, the optometrist should document the refusal, explain the risk of permanent vision loss, offer alternatives, and continue to urge emergency care. Good documentation protects the patient and demonstrates that the optometrist recognized the limits of optometric scope.