Intraocular pressure measurement in the emergency

0 downloads 7 Views 635KB Size Report
right eye has reduced to hand motion. Upon initial digital exam- ination, the IOP of the right eye seemed very high and was sub- sequently found to be 80 mm Hg ...

Downloaded from on June 20, 2015 - Published by

Images in medicine

Intraocular pressure measurement in the emergency room INTRODUCTION Intraocular pressure (IOP) assessment is a valuable skill for any physician working in the emergency room. Measuring the IOP digitally (when the examiner uses his fingers to evaluate a patient’s IOP) or with a simple inexpensive tonometer can aid in the diagnosis of vision-threatening ocular conditions (figures 1 and 2). The following case illustrates the usefulness of this examination in the workup of a young patient presenting with severe headache.

CASE REPORT A 51-year-old patient arrived in the emergency department complaining of having a severe headache for the past 2 days.

Figure 1 Measuring the intraocular pressure using digital examination. The aim of this technique is to assess the force required to indent the orbital wall. The patient is asked to shut his eyes and look down. Gentle pressure is applied alternately to the superior part of the lid by both index fingers.2

Figure 2 This rebound tonometer contains a lightweight disposable probe that measures the intraocular pressure (IOP) by a brief contact with the cornea. Measuring of IOP can be achieved with a few practices and with no need for topical anaesthesia.3 Adapted from ref. 4. The headaches were right-sided and frontal, mainly located over his right eye. There was no history of head injury or trauma. The patient denied having any weakness, loss of consciousness, loss of sensation or speech difficulties. His only surgical history was a cataract extraction operation on his left eye, 7 years earlier. Past medical history and family history were unremarkable. He stated that vision in his right eye had been deteriorating for the past year due to presenile cataract formation. He had been advised to undergo cataract removal surgery several times, but declined the surgery because of a busy schedule. His vital signs were within normal parameters. Physical examination found no evidence of acute focal neurological deficits; cardiovascular, respiratory and neurological examinations came back normal. All blood test results were within normal range. Ophthalmological examination revealed that visual acuity in his right eye has reduced to hand motion. Upon initial digital examination, the IOP of the right eye seemed very high and was subsequently found to be 80 mm Hg (normal range 8–21 mm Hg)

Figure 3 (A) Right eye, slit-lamp examination: hypermature cataract in a deep anterior chamber, with pigmented cells and debris adhering to the posterior surface of the cornea. Right: zoom on a white reflex and a hazy cornea. (B) Graphic presentation of protein leakage from a mature cataract, which leads to an inflammation response, clogging the trabecular meshwork and raising the intraocular pressure. Phacolytic glaucoma is most common in the debilitated elderly and in rural populations with poor access to medical care.5 In this unusual case, phacolytic glaucoma occurred in a young patient living in an urban environment. Adapted from ref. 6. Achiron A, et al. Postgrad Med J October 2014 Vol 90 No 1068


Downloaded from on June 20, 2015 - Published by

Images in medicine using applanation tonometry. In this eye, the conjunctiva was hyperaemic and the cornea was hazy and oedematous, with some pigment precipitate on the corneal endothelium. The anterior chamber was deep with a few cells. The right pupil was non-responsive to light, and the lens was a hypermature cataract. The left eye was pseudophakic but otherwise normal. The sudden increase in IOP, in combination with the clinical presentation, supported the diagnosis of phacolytic glaucoma (figure 3). After normal kidney function was verified, the patient was started on intravenous carbonic anhydrase inhibitors (500 mg four times a day) and eye drops to control the IOP. Cataract removal surgery was performed 2 days later. At the first follow-up visit, the patient was free of pain, with improved visual acuity and an IOP of 16.

DISCUSSION IOP measurement in the emergency room is important and we encourage physicians to master this technique manually or with assisted device (figures 1 and 2). Digital IOP examination is a simple employed procedure and is one of the oldest ways to evaluate IOP. In addition, various hand-held tonometers can provide rapid assessment of the IOP. These portable devices have the accuracy and reproducibility to detect abnormal values.1 The techniques presented here may be useful in the emergency room setting for evaluating whether a headache is caused by a very high IOP.2

Correspondence to Dr Asaf Achiron, Department of Ophthalmology, The Edith Wolfson Medical Center, Holon 58100, Israel; [email protected] Contributors AA designed, AA, KA and RNA drafted and EB supervised this manuscript. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.

To cite Achiron A, Arbid K, Noy Achiron R, et al. Postgrad Med J 2014;90:603– 604. Received 17 March 2014 Revised 25 July 2014 Accepted 4 August 2014 Published Online First 1 September 2014 Postgrad Med J 2014;90:603–604. doi:10.1136/postgradmedj-2014-132688


2 3


Asaf Achiron,1,2 Khamis Arbid,3 Romi Noy Achiron,2 Elisha Bartov1,2 1

Department of Ophthalmology, The Edith Wolfson Medical Center, Holon, Israel Tel Aviv University, Tel Aviv, Israel 3 Emergency Department, Russells Hall Hospital, Dudley, UK





Briesen S, Schulze Schwering M, Roberts H, et al. Minimal cross-infection risk through Icare rebound tonometer probes: a useful tool for IOP-screenings in developing countries. Eye (Lond) 2010;24:1279–83. Heidary F, Gharebaghi R, Heidary R. Palpation by blind examiners: a novel approach for glaucoma screening. Clin Ophthalmol 2010;4:671–2. Kim HS, Park KH, Jeoung JW. Can we measure the intraocular pressure when the eyeball is against the pillow in the lateral decubitus position? Acta Ophthalmol 2013;91:e502–5. The iCare Tonometer: A Kinder, Gentler Way To Measure IOP. http://caryoptometric. com/2011/05/17/icare-tonometer-454 (accessed Jun 2014). Pradhan D, Hennig A, Kumar J, et al. A prospective study of 413 cases of lens-induced glaucoma in Nepal. Indian J Ophthalmol 2001;49:103–7. Lens Induced Glaucoma. conditions/glaucoma-lens_induced (accessed Jun 2014).

Achiron A, et al. Postgrad Med J October 2014 Vol 90 No 1068

Downloaded from on June 20, 2015 - Published by

Intraocular pressure measurement in the emergency room Asaf Achiron, Khamis Arbid, Romi Noy Achiron and Elisha Bartov Postgrad Med J 2014 90: 603-604 originally published online September 1, 2014

doi: 10.1136/postgradmedj-2014-132688 Updated information and services can be found at:

These include:

References Email alerting service

Topic Collections

This article cites 4 articles, 0 of which you can access for free at: Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.

Articles on similar topics can be found in the following collections Ophthalmology (84) Headache (including migraine) (29) Pain (neurology) (199) Emergency medicine (102) Immunology (including allergy) (346)


To request permissions go to: To order reprints go to: To subscribe to BMJ go to:

Suggest Documents