A physician-validated, board-style question from the Active Transport QBank. Try it, then check the reasoning for every option.
A 50-year-old man presents with a rapid onset of severe, right periorbital pain, an ipsilateral throbbing headache, and blurred vision for the past hour. The patient says he was out walking with his friend when he felt short of breath. His friend gave him a puff of his rescue inhaler because it often relives his breathlessness, but, soon after that, the patient's eye symptoms started. No significant past medical history. His pulse is 100/min and regular, respirations are 18/min, temperature is 36.7°C (98.0°F), and blood pressure 130/86 mm Hg. On physical examination, his right pupil is fixed and dilated. Fundoscopic examination of the right eye is difficult due to 'clouding' of the cornea, and tonometry reveals increased intraocular pressure (IOP). Ibuprofen, acetazolamide, timolol, pilocarpine, and topical prednisolone are administered, but the patient's symptoms are only slightly reduced. Which of the following is the next best step in the management of this patient?
-
A
Administer systemic steroids.Incorrect. Systemic steroids are not the next definitive intervention — they don't lower IOP fast enough to save vision in acute angle closure.
-
B
Get an urgent ophthalmology consultation.Correct. definitive treatment is laser/surgical iridotomy by an ophthalmologist; the next step in the ED is urgent ophthalmology consultation to arrange this.
-
C
Add latanoprost.Incorrect. Latanoprost (prostaglandin analog) works slowly and may worsen inflammation in acute angle-closure attacks — not the appropriate next step.
-
D
Perform emergency iridotomy.Incorrect. While iridotomy IS the definitive treatment, ED physicians typically don't perform this procedure — the next step is to call ophthalmology, who will perform iridotomy.
-
E
Administer intravenous mannitol.Incorrect. IV mannitol can transiently lower intraocular pressure as a temporizing measure, but it does not address the underlying angle closure and is not the next step in a patient already failing maximal medical therapy — definitive iridotomy via ophthalmology is required.
↑ Tap an answer to reveal the reasoning
Answer: B. Rapid-onset unilateral periorbital pain, headache, blurred vision, fixed dilated pupil, corneal clouding, and elevated intraocular pressure define ACUTE ANGLE-CLOSURE GLAUCOMA. The trigger here was an inhaled albuterol or anticholinergic rescue inhaler (medications with anticholinergic/sympathomimetic effects dilate the pupil and can precipitate angle closure in predisposed eyes with shallow anterior chambers).
Medical management has already been given (acetazolamide reduces aqueous production, timolol reduces production via beta-blockade, pilocarpine causes miotic constriction to pull the iris away from the angle, prednisolone reduces inflammation, and analgesics). Symptoms only slightly improved, meaning medical management has not broken the attack.
The DEFINITIVE treatment is LASER PERIPHERAL IRIDOTOMY (or surgical iridectomy), which creates a hole in the iris to bypass the pupillary block and equalize pressure between the posterior and anterior chambers. However, because emergency iridotomy requires an ophthalmologist with specialized equipment, the IMMEDIATE next step in an emergency department setting is URGENT OPHTHALMOLOGY CONSULTATION. The ophthalmologist will then perform the iridotomy or further escalate medical therapy.
Additional latanoprost (prostaglandin analog) doesn't act fast enough; systemic steroids are not first-line. Note that prostaglandin analogs are relatively contraindicated in acute angle-closure because they can worsen inflammation.
**Why each option:**
**A.** Systemic steroids are not the next definitive intervention — they don't lower IOP fast enough to save vision in acute angle closure.
**B.** Correct — definitive treatment is laser/surgical iridotomy by an ophthalmologist; the next step in the ED is urgent ophthalmology consultation to arrange this.
**C.** Latanoprost (prostaglandin analog) works slowly and may worsen inflammation in acute angle-closure attacks — not the appropriate next step.
**D.** While iridotomy IS the definitive treatment, ED physicians typically don't perform this procedure — the next step is to call ophthalmology, who will perform iridotomy.