Acute Angle Closure Glaucoma Presented with Nausea and Epigastric Pain

Abstract

A 78-year-old woman was admitted to our department with nausea, vomiting, epigastric pain, and intense headache of the left side of 1 day duration. She had suffered from diabetes mellitus for the last 7 years and was being treated with a combination of metoformin (850 mg twice daily) and glimepiride (1 mg/day). In addition, for the last 5 years she was being treated for atrial fibrillation with acenocoumarol 1 mg/day. The patient also suffered from lumbar pain due to osteoarthritis and was being treated with a combination of paracetamol plus orphenadrine citrate (Norgesic) (450 + 35 mg per day) for the last 10 days.On admission, the patient was afebrile and the clinical examination revealed obesity, high arterial blood pressure (170/95 mmHg), and epigastric pain without clinical signs of peritonitis. Her left eye was red, and the pupil was more dilated and less reactive to light compared to the right eye. Laboratory findings included a hematocrit measurement of 44.5%, WBC at 8,900/mm 3 , C-reactive protein of 4 mg/l, and total bilirubin at 1.3 mg/dl (direct 0.5 mg/dl). An ultrasound of the upper abdomen was without abnormal findings. A CT scan of the head was normal. Antiemetics and proton pump inhibitors were initiated, and with the diagnosis of possible conjunctivitis, a tobramycin eye ointment was given. The next day, the patient's nausea had improved, but her headache had worsened and she reported a blurred vision from her left eye and photophobia. After reevaluation of her history and clinical findings, a digital tonometer was used which revealed an opening pressure of 62 mmHg on the left and 32 mmHg on the right eye. The diagnosis of acute angle closure glaucoma (AACG) was made, treatment was immediately started (eye drops of pilocarpine 2% and timolol 0.5%, acetazolamide 250 mg per os, and mannitol 1.0 mg/kg IV), and the patient was transferred to the ophthalmology department for further evaluation and management.