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Glaucoma

A Case of Acute Chest Pain After Acetazolamide to Treat Uncontrolled Increased Intraocular Pressure

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.

1 Credit CME

JAMA Ophthalmology

Published Online: March 16, 2023

JAMA Ophthalmology Clinical Challenge

Article Information and Disclosures

Oladipupo Anibire, BS¹;

Hasenin Al-Khersan, MD²;

Basil K. Williams Jr, MD^2,3

Author Affiliations

¹Meharry Medical College, Nashville, Tennessee
²Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida
³Department of Ophthalmology, University of Cincinnati College of Medicine, Cincinnati, Ohio

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A 61-year-old Black man with hypertension and diabetes presented with decreased vision 3 months after uneventful cataract surgery in his left eye. He had undergone laser retinopexy for retinal tears in his right eye and a scleral buckle and vitrectomy for a retinal detachment in his left eye 1 year earlier. Best-corrected visual acuity (BCVA) was 20/40 OD and counting fingers OS. Intraocular pressure (IOP) was 14 mm Hg in the right eye and 44 mm Hg in the left eye. Anterior segment examination of the right eye was unremarkable, while ophthalmoscopic examination showed vascular attenuation and treated retinal breaks. In the left eye, microcystic corneal edema and Descemet membrane folds limited examination, but no residual lenticular fragments or neovascularization of the iris or angle were seen. The patient was discharged taking timolol, dorzolamide, brimonidine, and prednisolone. Twelve days later, the cornea had cleared and IOP in the left eye improved to 32 mm Hg. Gonioscopy revealed 360° of anterior synechiae and complete angle closure, which was documented on ultrasound biomicroscopy (Figure 1). The patient started treatment with 500 mg of acetazolamide daily and referred to the glaucoma service for surgical evaluation.

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Acute chest syndrome induced by acetazolamide in a patient with previously undiagnosed sickle cell disease.

D. Perform hemoglobin electrophoresis

Obtaining blood cultures, performing a vitreous tap, and injecting antibiotics (choice A) would be an appropriate choice of action in suspected endogenous endophthalmitis. However, while this patient had systemic symptoms, the examination did not demonstrate findings consistent with endophthalmitis, such as vitritis, chorioretinal infiltration, fibrin, a hypopyon, or conjunctival hyperemia. Laser iridotomy (choice B) would be useful if the patient demonstrated acute angle closure. While acute angle closure can cause nausea and vomiting, it would not be expected to cause acute chest pain or respiratory distress. Additionally, pupillary block was not found on examination. Finally, observation (choice C) is inappropriate in this systemically unstable patient.

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Article Information

Corresponding Author: Basil K. Williams Jr, MD, Department of Ophthalmology, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Ste 5414, Cincinnati, OH 45267-0527 (basilkwilliams@gmail.com).

Published Online: March 16, 2023. doi:10.1001/jamaophthalmol.2023.0193

Conflict of Interest Disclosures: Dr Al-Khersan reported receiving personal fees from RegenxBio, Genentech, and EyePoint Pharmaceuticals outside the submitted work. Dr Williams reported receiving consulting fees from Allergan, Castle Biosciences, EyePoint Pharmaceuticals, Genentech, and Regeneron outside the submitted work. No other disclosures were reported.

Additional Contributions: We thank Angela R. Elam, MD, Department of Ophthalmology and Visual Sciences, University of Michigan W.K. Kellogg Eye Center, Ann Arbor, Michigan, for assistance in editing this manuscript. Dr Elam did not receive compensation for her contribution. We thank the patient for granting permission to publish this information.

References

Institute for Health Metrics and Evaluation. Sickle cell disorders—level 4 causes. Published October 15, 2020. Accessed September 20, 2022. https://www.healthdata.org/results/gbd_summaries/2019/sickle-cell-disorders-level-4-cause

Centers for Disease Control and Prevention. Data and statistics on sickle cell disease. Published May 2, 2022. Accessed September 16, 2022. https://www.cdc.gov/ncbddd/sicklecell/data.html

Berríos RR , Dreyer EB . Traumatic hyphema. Int Ophthalmol Clin. 1995;35(1):93-103. doi:10.1097/00004397-199503510-00010 PubMed Google Scholar Crossref

Bansal S , Gunasekeran DV , Ang B , et al. Controversies in the pathophysiology and management of hyphema. Surv Ophthalmol. 2016;61(3):297-308. doi:10.1016/j.survophthal.2015.11.005 PubMed Google Scholar Crossref

Crouch ER Jr , Frenkel M . Aminocaproic acid in the treatment of traumatic hyphema. Am J Ophthalmol. 1976;81(3):355-360. doi:10.1016/0002-9394(76)90254-3 PubMed Google Scholar Crossref

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.