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Acute Vision Loss in a Patient With Eye Pain
Case Study
A rapid response event was initiated by a bedside nurse for a patient with acute vision loss. On arrival of first responders, the patient was lying in bed in severe pain, stating she could not see out of her right eye. Per the bedside nurse report, the patient was a 64-year-old female with a history of hypertension, heart failure, gastroesophageal reflux disease (GERD), and allergic rhinitis. She was admitted for heart failure exacerbation. A few minutes before initiating this code, the patient endorsed a sudden loss of vision in the right eye, which did not improve in the past 10 min. Upon medication review, the patient was currently being treated with furosemide for heart failure, and her home medications of lisinopril, carvedilol, and insulin were continued. She was also being given her home dose of loratadine for chronic allergic rhinitis. Her home medication of hydrochlorothiazide (HCTZ) was held inpatient while she was getting furosemide. The nurse stated the patient has been nauseous and has thrown up a few times since the pain started. The patient reported halos in her visual field and severe headache.
Vital Signs
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Temperature: 98.3 °F, axillary
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Blood Pressure: 145/97 mmHg
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Heart Rate: 102 beats per min (bpm) – sinus tachycardia on telemetry
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Respiratory Rate: 17 breaths per min
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Pulse Oximetry: 97% on room air
Physical Examination
The patient was an overweight adult female lying upright in bed in acute distress. She was alert and oriented and endorsed a 10/10 right eye pain. Her eye exam showed conjunctival injection, non-reactive mid-dilated pupil on the right eye, clouded cornea, photophobia, tenderness to palpation over the right eye, and increased rigidity of the right eye ball compared to the left. A cardiovascular exam revealed tachycardia without a murmur. A quick motor and sensory exam did not reveal any acute abnormalities except for the findings in the right eye.
Interventions
The patient showed characteristic features such as acute vision loss associated with headache, nausea, conjunctival injection, photophobia, and a non-reactive mid-dilated pupil consistent with acute angle-closure glaucoma. Computed tomography (CT) scan of the head was ordered to rule out intracranial ischemic stroke/bleed. A stat ophthalmology consult was called, and recommendations were taken over the phone while waiting for them to evaluate the patient physically. Per expert recommendations, pressure-lowering eye drops were administered. Timolol maleate, apraclonidine, and pilocarpine were given 1 min apart. CT of the head was done and was normal. On arrival of ophthalmology team, tonometry was done, revealing intraocular pressure (IOP) of 40 mmHg. Once the diagnosis was confirmed by ophthalmology, acetazolamide 500 mg oral was given. The patient was retained on the floor.
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