The eye, the eye! OSCE by Michael

 
You have 3 minutes reading time. This OSCE will run for a maximum of 7 minutes.

Scenario:

A 63yo man has presented to ED with an acutely painful red left eye after watching a movie. The pain is severe, his vision is blurry, and he is feeling nauseated. He has been assessed by an RMO who is concerned he has acute angle closure glaucoma.

Instructions for the candidate

You are the consultant on. You are to review the assessment with the RMO (you will not be examining the patient) and then advise on initial management.

Domains being examined

  • Medical Expertise
  • Prioritisation And Decision Making
  • Scholarship and Teaching
 
The candidate has 3 minutes reading time. This OSCE is expected to run for a maximum of 7 minutes.

For the actor

RMO: You are a junior RMO new to ED and not completely familiar with eye examination. You have found the following, but need to be prompted to reveal it:

History:
Sudden onset of left eye pain and blurring of vision after watching a movie. Never had this before. No history of eye conditions. Pain is severe and constant and feels deep in the eye. He has vomited once and feels nauseated.
PHx hypertension, diet-controlled T2DM. Meds: perindopril. NKDA. FHx: father had glaucoma.

Examination:
Left eye red, teary. Left pupil semi-dilated (size 6) and non-reactive, indirect reaction to right side intact. Pain worse with light. Extraocular movements intact. VA right: 6/12, left: gross movement only. You have not done a slit lamp exam.

You are unsure how to use the tonometer and have brought it with you to be instructed.

You are unsure of any treatment measures except acetazolamide (but you are unsure of the dose).

For the examiner

Requirements: tonometer

Domains Assessment Objectives

Medical Expertise
Assessment and management of acute angle-closure glaucoma

Prioritisation And Decision Making
Clear directed management plan

Scholarship and Teaching
Clear and supportive educational interaction

Other Assessment Notes

Introductions and approach

1. Assessment
*History
- Risk factors (PHx, FHx, eye conditions, known shallow anterior chamber, eye drops, medications (eg ipratropium), ethnicity, glasses / contacts)
- Onset and progression, duration
- visual change (eg halo)

*Examination
- prompt for general appearance, pupil reaction
- visual acuity
- anterior chamber cloudiness
- conjunctival injection, discharge
- IOP (not done)

2. Use of tonometer

3. Management
*identify emergent nature of Mx
*Drug therapy
- aggressive management indicated due to significant visual loss
- Reduce production
-- Timolol 0.5% 1dr every 30mins - 1/24
-- Acetazolamide 500 mg IV (250 orally tds after)
-- +/- Mannitol 1g/kg
- Improve aqueous flow
-- Pilocarpine 2% drops every 5min for 1h (contracts pupil)
-- Latanoprost 0.005% 1 dr/2h for 6h
*Surgical
- iridotomy or iridectomy

*Adjuncts
- antiemetics
- analgesia
- dark room

*Disposition
- urgent opthalmology review

Bonus:
- pathogenesis, using word Schlemm during OSCE
- complications / adverse effects of medications


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Comments:

I believe adjunct treatment should be a bright room instead of dark given we want pupillary constriction.

Ignatius at 20:55 12 May 2018