Eye Pain and Visual Change 495456.A 60-year-old man with a history of hypertension and migraine
headaches presents to the ED with a headache. He describes left-sided
headache and eye pain that is associated with nausea and vomiting. The
patient has a long history of migraines, but says his migraines do not usually
include eye pain. On examination, his temperature is 97.6°F, HR 84 beats per
minute, RR 12 breaths per minute, and BP 134/80 mm Hg. His neurologic
examination is normal. His left eye is mid-dilated and nonreactive. His cornea
is cloudy. His corrected visual acuity is 20/50 in the left eye and 20/20 in the
right eye. What is the most appropriate next step in management?
a. Administer hydromorphone
b. Head CT scan
c. Check IOP
d. Check erythrocyte sedimentation rate (ESR)
e. Discharge patient
457.A 22-year-old presents to the ED for left eye pain. He was in an alter-
cation yesterday and was punched in the left eye. On examination, his left
eye is ecchymotic and the eyelids are swollen shut. He has tenderness over
the infraorbital rim, but no step-offs. You use an eyelid speculum to examine
his eye. His pupils are equal and reactive to light. His visual acuity is normal.
On testing extraocular movements, you find he is unable to look upward
with his left eye. He also complains of diplopia when looking upward. Fun-
duscopic examination is normal. What is the most likely diagnosis?
a. Orbital blowout fracture
b. Ruptured globe
c. Retinal detachment
d. Cranial nerve III palsy
e. Traumatic retrobulbar hematoma
458.You are examining the pupils of a patient. On inspection, the pupils
are 3 mm and equal bilaterally. You shine a flashlight into the right pupil
and both pupils constrict to 1 mm. You then shine the flashlight into the
left pupil and both pupils slightly dilate. What is this condition called?
a. Anisocoria
b. Argyll Robertson pupil
c. Afferent pupillary defect
d. Horner syndrome
e. Normal pupil reaction