Painful Red Eye with a Mid-Dilated Pupil
A 58-year-old hyperopic woman presents to the emergency department with a 2-day history of severe left eye pain, redness, blurred vision, and halos around lights. She has vomited twice. Visual acuity is 20/200 OS and 20/30 OD. Left intraocular pressure is 54 mmHg; right is 16 mmHg. The left cornea is diffusely edematous, the anterior chamber is shallow, and the pupil is mid-dilated and fixed. The right eye has a narrow peripheral anterior chamber on slit-lamp estimation. She is hypertensive at 162/94 mmHg and has no previous eye surgery. Gonioscopy cannot be performed because of corneal edema. She took ibuprofen for the pain without relief. She has no history of glaucoma and no family history. She wears reading glasses and has never used eye drops. She is not pregnant.
1. What immediate treatment would you start, and why is pilocarpine not the first drug?
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Lower the IOP and clear the cornea. I would start topical timolol, brimonidine, and prednisolone acetate, plus systemic acetazolamide 500 mg IV followed by 250 mg every 6 hours, and an antiemetic/analgesic. If IOP remains very high or the patient is vomiting, add IV mannitol 20% 1–2 g/kg with careful monitoring in a hypertensive patient. Pilocarpine is not first-line because the iris sphincter may be ischaemic and unresponsive, and it can increase anterior lens–iris contact; I would use it only after IOP falls and the cornea clears. I would avoid mydriatics and keep the patient monitored. Definitive treatment is laser peripheral iridotomy once the cornea is clear.
2. What would you do for the fellow eye and for definitive management?
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The fellow eye has narrow angles and is at high risk, so it needs prophylactic laser peripheral iridotomy after the acute attack is controlled, usually within days. For the affected eye, perform laser peripheral iridotomy as soon as the cornea is clear enough; if the angle remains appositional or the eye is pseudophakic, reassess. Gonioscopy after clearing determines synechiae and residual angle closure. If laser iridotomy cannot be performed or fails, surgical iridectomy or lens extraction may be needed. I would not discharge the patient without a documented plan for both eyes.
3. What follow-up and counselling are needed?
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Check IOP, cornea, gonioscopy, optic nerve, and visual field after the acute phase; arrange follow-up within days and then at intervals. Warn about recurrent pain, redness, halos, nausea, or reduced vision, and advise urgent return. Review medications that can precipitate angle closure with the physician, but do not stop essential drugs without discussion. Document the narrow-angle diagnosis in the record and ensure the patient and family understand that the fellow eye also needs treatment. Long-term monitoring for glaucoma is needed because angle damage may persist.