Download Management of a patient with acute angle closure glaucoma

Management of a patient with acute angle closure glaucoma:
Part 1 - Assessment and medical/surgical treatment
Agnes Lee MPhil, Bsc (Hons), PGCE, DipN, RN, RM, OND
ABSTRACT
This is a two-part case study that discusses the care and management of a patient with acute angle closure glaucoma. The
first part of this article provides the background to the case study. It examines the normal and abnormal anatomy and
physiology of acute angle closure glaucoma and takes into account the presenting signs and symptoms. Findings from the
slit lamp examination will provide a framework for discussion. An individualised medical plan of care for acute angle
closure glaucoma will be discussed based on research evidence. The second part of the article examines the nursing care of
the patient. The Roper-Logan-Tierney model of nursing is utilised to provide a framework for the assessment, planning,
implementing and evaluation of the patient (Roper et al 1996). The case study will also explore the patient's beliefs about
his illness and issues of adherence. The role of the glaucoma nurse in the management of patients with glaucoma will also
be discussed.
Key words: Acute glaucoma, individualised care management, advanced nursing practice.
Journal of ESONT 2006; 1(2): 10-15
© 2006 ESONT
Summary of case study
Summary
Mr J is a 67 year old hypermetropic gentleman who was
referred by his GP with a three day history of an acute,
painful left eye and blurring of vision. A diagnosis of left
acute angle closure glaucoma was made.
An individualised medical plan was put into action.
Immediate medical treatment of a stat dose of
intravenous and oral acetazolamide 500mgs was
instigated. He was admitted and commenced on guttae
prednisolone forte and pilocarpine 4% four times a day to
his left eye. Due to Mr J's asthmatic status, topical betablockers were avoided and guttae Iopidine prescribed
instead. The next day, the IOP in his left eye was reduced
to 10mmHg. As his left cornea was still oedematous, he
underwent an uneventful right YAG peripheral iridotomy
before he was discharged. He attended as an outpatient
two days later to undergo a left YAG peripheral iridotomy.
His discharge topical medications included prednisolone
four times a day to both eyes, Iopidine and pilcocarpine
three times a day to his left eye only. He was also
prescribed acetazolamide tablets 250mgs three times a
day for three days.
Mr J's nursing care on the ward was based on the RoperLogan-Tierney model for nursing (Roper et al 1996). Since
the pivotal concept of the model is described in the
Activities of Living, this provides the framework for the
assessment, planning, implementing and evaluation of
Mr J's care.
Mr J was subsequently discharged five months later with
no adverse damage to his eyes.
10
Journal of ESONT Volume 1 Issue 2
INTRODUCTION
Mr J is a 67 year old hypermetropic gentleman who was
referred by his general practitioner (GP) with a three day
history of an acute, painful left eye and blurring of vision.
A provisional diagnosis of an acute anterior iritis
associated with a history of cervical spondylitis was made
by his GP. At the hospital, his corrected vision was 6/5 in
his right eye and 6/12 in his left eye. Slit lamp examination
showed bilateral shallow anterior chambers and his
intraocular pressure in his right and left eye was 17mmHg
and 65mmHg respectively. His left pupil was dilated and
unreactive with a mild anterior chamber reaction.
His medical history included angina, hypertension,
hypercholestremia, cervical spondylitis and asthma. His
medications included verapamil 120mgs, atavastin 10mgs,
soluble aspirin 75mgs and Beclaforte and salbutamol
inhalers. He was also possibly allergic to tetracycline.
When Mr J’s assessment was complete, he was diagnosed
with having acute angle closure glaucoma.
ANATOMY AND PATHOPHYSIOLOGY OF
ACUTE ANGLE CLOSURE GLAUCOMA
Angle closure glaucoma is a condition in which the iris is
apposed to the trabecular meshwork at the angle of the
anterior chamber of the eye. Angle closure may occur via
two mechanisms. The iris may be pushed forward into
contact with the trabecular meshwork, as in pupillary block
or plateau iris, or it may be pulled anteriorly as occurs
with other inflammatory conditions such as acute anterior
uveitis. Approximately 90% of patients with angle closure
glaucoma have relative block as the underlying
mechanisms (Ritch 2001). The remaining 10% have
another mechanism or combination of mechanisms other
than, or in addition to, pupillary block.
© 2006 ESONT