Acute painful red eye — suspected angle-closure glaucoma

PLAB 2 & PRES 3 · ophthalmology · hard · 8 minutes

Candidate brief

You are an FY2 doctor/SHO in the Emergency Department. Mrs Margaret Lewis, 64, presents with sudden severe left-eye pain, redness, blurred vision, headache and vomiting. Assess her urgently, explain the likely diagnosis and initiate an appropriate emergency management and escalation plan. Verbalise any examinations, investigations and treatments you would undertake.

What examiners look for

Acute angle closure occurs when the iris obstructs drainage of aqueous fluid, causing a rapid and dangerous rise in intraocular pressure. Typical symptoms include: Severe unilateral eye or periocular pain. A red eye. Rapidly reduced or misty vision. Rainbow-coloured haloes around lights. Headache. Nausea and vomiting. Typical examination findings include circumcorneal injection, corneal oedema, a shallow anterior chamber, a fixed mid-dilated pupil and a markedly raised intraocular pressure. Always measure visual acuity in each eye before treatment when feasible. Examine both eyes because the other eye may have a similarly narrow drainage angle. Do not pharmacologically dilate a pupil when acute angle closure is suspected. Contact ophthalmology immediately. Give analgesia and antiemetic treatment and obtain IV access. Initial pressure-lowering treatment usually combines systemic acetazolamide and topical medicines under the local ophthalmology protocol. Check allergies, renal function and relevant cardiac or respiratory contraindications first. Pilocarpine should not be given blindly. It may be ineffective while intraocular pressure is extremely high and can worsen certain secondary mechanisms of angle closure. Urgent laser peripheral iridotomy creates a small opening in the iris, allowing aqueous fluid to bypass the pupillary blockage. The other eye commonly also requires preventive treatment. Medication initially lowers pressure and clears the cornea but does not replace definitive specialist treatment. Do not discharge until intraocular pressure is controlled and an ophthalmologist has agreed the treatment and follow-up plan. The patient must not drive while vision is impaired or following emergency treatment.

Guideline references

Practise this station

Role-play it with an AI patient and get feedback against the full marking scheme. Create a free account — 3 stations per month free.