USMLE Prep Course

A 70-year-old woman presents with right-sided severe headache associated with nausea, vomiting, eye pain, and blurred vision. She states her symptoms started shortly after entering her car at night. She reports seeing halos around the traffic lights. Her past medical history is remarkable only for hypertension.

On examination, the patient appears uncomfortable. Vital signs are normal. The left conjunctiva is clear with a grossly clear cornea and reactive pupil. The right eye is remarkable for diffuse conjunctival injection, a cloudy cornea, and a nonreactive mid-dilated pupil. Visual acuity is 20/40 OS and 20/200 OD. Neurologic examination findings are otherwise normal, including intact extraocular movements.

Which of the follow statements is true regarding this patient’s most likely diagnosis?

 Relief of the headache with oxygen is diagnostic.
 Tonometry will confirm the diagnosis.
 Erythrocyte sedimentation rate (ESR) will confirm the diagnosis.
 Computed tomography (CT) of the brain will confirm the diagnosis.

Correct Answer:

Tonometry will confirm the diagnosis.

Educational Objective:

Discuss findings of acute angle closure glaucoma in comparison with other serious causes of unilateral headaches.

Key Point:

Acute eye pain, headache, and vision disturbance precipitated by pupillary dilation (entrance into low light environment) associated with a red eye, cloudy cornea, fixed mid-dilated pupil, and firm globe is consistent with acute angle closure glaucoma.

Explanation:

Acute angle closure glaucoma, temporal arteritis, cluster headache, and migraine headache all may present with unilateral headache and vision disturbance with or without nausea and vomiting. Tonometry is diagnostic for acute angle closure glaucoma—an elevated intraocular pressure (IOP; typically 40-80 mm Hg) confirms glaucoma and thereby excludes the other options.

An elevated ESR is a diagnostic criterion for temporal arteritis. Termination of the headache with oxygen suggests an etiology of cluster headache. In addition, younger age at onset and miosis (rather than mydriasis) are expected with cluster headache, not acute angle closure glaucoma. CT is not diagnostic of glaucoma.

Acute glaucoma of the right eye with injection and a mid-dilated, fixed and cloudy pupil

References:

Goldstein JN, Edlow JA. Headache (Chapter 101). In: Adams JG, et al. Emergency Medicine: Clinical Essentials. 2nd ed., 2012:881-889.e2

Guluma K, Lee JE. Ophthalmology (Chapter 61). In Walls, R, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018:790-81.e3

Kwiatkowski T, Friedman BW. Headache disorders (Chapter 93). In: Walls R, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018:1265-1277e2

Russi CS, Walker L. Headache (Chapter 17). In Walls R, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018:153-159.e1

Walker RA, Adhikari S. Eye Emergencies (Chapter 241). In: Tintinalli JE, et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed., 2015

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