Eye Pain and Visual Change Answers 503clavulanate orally (b)and close follow-up with their regular doctor. Chil-
dren less than 5 years old are at risk for systemic bacteremia and should be
admitted for IV antibiotics. Patients with allergic reactions have swelling and
erythema of the eyelids, but no fever or tenderness to palpation. These
patients may be treated with artificial tears (e)and antihistamines, such as
(a)diphenhydramine.
456.The answer is c.(Tintinalli, pp 1459, 1461-1462.)This patient has
acute angle-closure glaucoma,when the aqueous humor production in the
posterior chamber of the eye is unable to drain through the anterior chamber
and the resultant obstruction causes increased IOP.On examination, patients
with increased IOP have a mid-dilated, nonreactive pupil with corneal cloud-
ingand decreased vision. The diagnosis is clenched by checking the IOP with
a tonopen or tonometer. Normal IOP is 10 to 21 mm Hg. Patients with
increased IOP should be treated with medications to decrease production of
aqueous humor. Checking IOP is a simple, rapid test that should be per-
formed on all patients with headache and orbital pain. If this test is negative,
other causes of headache and eye pain should be investigated.
This patient is not experiencing his typical migraine headache and he
has abnormalities on his physical examination. Discharging the patient with-
out further investigation is therefore inappropriate (e).Pain control is appro-
priate for this patient, but given his nausea and vomiting, he is not likely to
tolerate oral hydromorphone (a).Checking an ESR (d)is helpful if you sus-
pect temporal arteritis. Head CT scan (b)can be considered in the workup of
an atypical headache, but simpler tests, such as tonometry, should be per-
formed first.
457.The answer is a.(Tintinalli, pp 1457-1464, 1587-1588. Vassallo,
pp 251-256.)This patient has an orbital blowout fractureof the inferior
wall causing entrapment of the inferior rectus muscleandrestricted
eye motilitywith diplopia. A CT scan with thin cuts through the orbits can
confirm the diagnosis. Patients with this injury are generally started on oral
antibiotics because of the risk of infection with sinus wall fractures and may
follow-up with the institution’s appropriate surgical service in 3 to 10 days.
These injuries are associated with other eye problems and a careful eye exami-
nation must be performed to rule out abrasions, lacerations, foreign bodies,
hyphema, iritis, retinal detachment, and lens dislocation.
The patient has no evidence of a retinal detachment (c)given his normal
visual acuity and funduscopic examination. However, even with a normal