NMS Q&A Family Medicine

36 NMS Q&A Family Medicine80 mm Hg. Failure to rapidly lower intraocular pressurewill result in chronic uncontrolled intraocular hypertensionand permanent loss of vision. Immediate medicaltherapy includes intravenous mannitol or oral isosorbideif intravenous equipment is not immediately available,while administering pilocarpine to constrict the pupil andease the pressure in the Schlemm canals. Ultimately, therapyis surgical, such as laser partial iridectomy.11. The answer is E. The patient has iritis or anterioruveitis. Posterior uveitis involves the ciliary body (cyclitis),choroid, or both. Iritis is characterized by a meioticconstricted pupil and photophobia. Photophobia is aconsequence of the iridospasm and the aggravationthereof by light stimulation. Vision is blurred because ofthe nonspecific effects of abnormal ciliary body responsivenessbut especially so at distance because the spasticciliary body may disallow relaxation of accommodationfor distant vision. Most uveitis is non-granulomatous andassociated with and involving autoimmune processes,which can be seen by the presence of psoriasis in thispatient. Treatment of anterior uveitis usually consists oftopical glucocorticoids after confirmation by an ophthalmologist.Posterior uveitis and panuveitis are often treatedby systemic glucocorticoids. Rheumatological consultationwould be in order in those situations as well. Infectiouscauses are unusual and most often associated withimmune incompetence; these are treated by appropriateantibiotics.Angle closure glaucoma is characterized by a fixedmid-positioned pupil. Foreign bodies are rarely unseenand are signaled by the history of instantaneous symptoms.With a corneal-embedded foreign body (whichwould be fluorescein positive), there may be iridospasmthat is relieved by removal of the foreign body. Retinaldetachment of the left eye would be characterized by acurtainlike loss of vision rather than blurred vision and isusually painless. Bacterial conjunctivitis manifests muchpurulent exudate, matting of the eyelids, and a fine“sandy” foreign body.12. The answer is E. The vignette describes Sjögren syndrome.It is an autoimmune disease characterized by drymouth (carious teeth as a result) and dry eyes, as well asloss of taste and smell, pancreatitis, pleuritis, and chronicobstructive lung disease in the absence of smoking.Among many associated or metachronous conditions areparotid gland enlargement and other autoimmune diseasessuch as Grave disease, Hashimoto thyroiditis, vitiligo,and rheumatoid arthritis. There is no increased riskof diabetes type II (although there may be an increasedrisk of type I, an autoimmune disease), atheroscleroticdiseases, multiple endocrine neoplasia type II, or colorectalcancers (nor other cancers).13. The answer is E. Chronic glaucoma (open angle glaucoma),caused by increased intraocular pressure thatinsidiously destroys vision, occurs gradually over a periodof years. African-Americans are more susceptible andshould be screened beginning at the age of 35, whereasthose with average risk should be screened starting at theage of 40. This occurs without causing pain but eventuallycausing loss of vision, first in the peripheral fields andthen involving central vision. A significant percentage ofpatients with chronic glaucoma have normal pressureopen angle glaucoma. These cases are diagnosed in primarycare by fundoscopy and visual field testing (seeQuestion 14).Being of African-American race confers nearly a fourfoldrisk of developing primary open angle glaucoma(4.7% prevalence vs. 1.3% for whites). In addition,African-Americans are at risk much earlier in life thanpeople of other races, which warrants their screening at anage as young as 20 years. Otherwise, age 50 years is a riskfactor (not 35 years). Neither being female nor of Mexicanor Indigenous American race is listed as a risk factorfor primary open angle glaucoma; nor is exposure to sunlight.However, the latter places one at risk for pterygium(a pinguecula that forms on the sclera and crosses the limbusto extend onto the cornea). Being of Eastern Asian raceis a significant risk factor for closed angle or acute glaucoma.Another risk factor for chronic glaucoma is diabetesmellitus. Chronic glaucoma is best prevented by routineintraocular tension measurements, every 2 years afterthe age of 40 years; abnormal readings are defined as24 mm Hg on repeated measurement. This measurementmay be taken in primary care offices by use of the inexpensiveSchiotz tonometer. As mentioned, these cases are diagnosedthrough more subtle means (see Question 14).14. The answer is A. A significant proportion of openangle glaucoma occurs without intraocular hypertension.This is a situation analogous to normal pressurehydrocephalus. Diagnosis in most of these cases can bemade early by finding a cup/disc ratio 0.3 (30%). Theearliest change in vision would be a narrowing ofperipheral vision rather than a decrease in central vision(visual acuity). A decrease in distant visual acuity canresult from an increase in the index of refraction (refractiondensity) brought about by hyperglycemia as in newor uncontrolled diabetes, among other causes. Chronicglaucoma exhibits no other physical findings, and nosymptoms until visual changes are apparent. Therefore,erythema is not a sign of chronic glaucoma. Papilledemadoes not occur with chronic glaucoma. Acute(angle closure) glaucoma, but not open angle glaucoma,results in pupil change, in the form of relative mydriasis(dilatation).