Ophthalmic emergency-room visits during the Covid-19 pandemic - a comparative study.

BACKGROUND: The goal of this study is to compare ophthalmic emergency room (OER) visits during the Coronavirus disease-19 (Covid-19) pandemic to those during a control period. METHODS: We compared all visits to the OER to Meir Medical Center in Israel, from March 15th to April 15th, 2020, during the Covid-19 pandemic and government mandated quarantine, to the same period in 2019. Factors analyzed were patient demographics, chief complaints, referral patterns, exam findings, treatments given, hospitalizations and surgical interventions. RESULTS: We included in this study 1311 visits of 1158 patients, 477 during the 2020 Covid-19 pandemic and 834 during the same period in 2019. The demographic distribution (age, gender, and ethnicity) was similar between the two periods. LogMAR visual acuity at presentation was worse during the Covid-19 pandemic (0.42 ± 0.6 and 0.34 ± 0.5 in 2020 and 2019 respectively; p = 0.025) and the number of emergent surgeries was higher (3.7% in 2020 vs 1.8% in 2019, p = 0.026). In 2019 there was a higher likelihood of involvement of both segments of the eye (4.82% versus 1.2%, p < 0.01) and more diagnoses were given to each patient (1 ± 0.5 versus 0.93 ± 0.35, p = 0.001; During the Covid - 19 pandemic medications (both topical and systemic) were prescribed more often (1.22 ± 0.95 in 2020 and 0.84 ± 0.67 in 2019, p < 0.001). CONCLUSIONS: OER visits were less frequent during the Covid - 19 pandemic as compared to 2019, though the demographics of the patients remained unchanged. Visits during the pandemic tended to be for more severe ocular conditions, with worse visual acuity at presentation and required more medical and surgical treatment which imply higher necessity of ocular evaluation. This analysis can aid healthcare resource management in similar scenarios in the future.

Ophthalmic Emergencies in the Field.

Ophthalmic problems account for up to 20% of emergencies in equine practice. Presenting problems may involve the periocular region, adnexa, or globe. Practitioners must have the experience to restrain horses with painful ocular conditions and the knowledge of how to perform a thorough eye examination. A range of clinical skills is required for the necessary diagnostic tests such as corneal cytology, ultrasound and tonometry, and common standing surgical procedures such as eyelid repair or instillation of a subpalpebral lavage system. Therapy, which may involve frequent administration of multiple medications, must be targeted to the specific diagnosis.

An evidence-based medicine audit of the ophthalmic emergency services unit of King Abdulaziz University Hospital (KAUH).

PURPOSE: To improve the interventions provided for patients presenting with acute ophthalmic conditions to the ophthalmic emergency unit through applying the best available evidences from quality literature for managing such conditions. METHODS: A retrospective cohort study at a tertiary eye care university hospital in Riyadh, Saudi Arabia, involving a two-phase audit of diagnosis-intervention was conducted. The first phase was done retrospectively for the duration from April 1 to May 30, 2014, after disseminating the results of the first phase to King Abdulaziz University Hospital ophthalmology department staff, and the second phase was done retrospectively for the duration from November 1 to December 30, 2015. The validity of outcomes was assessed through a literature search using Medline and the Cochrane Database of Systematic Reviews. The participants were masked on the study objectives to avoid Hawthorne's phenomenon (prescribing bias). RESULTS: In the first part of the audit, 73.2% out of 355 interventions were found to be evidence based. There was notable improvement of 80.9% in the number of evidence-based interventions in the second part of the audit. This improvement was statistically significant (p = 0.017). CONCLUSION: Evidence-based medicine audit can be a helpful tool to assess the performance and can lead to quality improve of the provided care by reducing the number of medical errors and refining medical decisions and interventions.

Urgent Management of Penetrating Ocular Injury: A Case Report and Review of the Literature.

Ocular globe injury is a severe ophthalmic emergency that requires immediate attention in the emergency department. In this case report, we present a 35-year-old male who suffered a penetrating ocular injury and globe rupture caused by a nail puncture. The patient presented with severe pain and visual loss and was treated with tetanus vaccination, empirical antibiotics, and pain control, followed by an urgent orbital computed tomography (CT) scan and consultation with an ophthalmologist. The CT scan revealed a retained nail in the ocular space, and an urgent operation was performed to repair the eyeball rupture, remove the intraocular foreign body, and perform an anterior vitrectomy. The patient was discharged 6 days after the operation with a visual acuity of 20/400 and an ocular trauma score of 34. This case highlights the importance of initial emergency physician decision-making and the need for a thorough history-taking and examination when encountering penetrating ocular injuries.

Branch retinal artery occlusion with congenital common carotid artery and internal carotid artery occlusion: A case report.

PURPOSE: To report a case of branch retinal artery occlusion (BRAO) of the left eye combined with left congenital common carotid artery occlusion (CCAO) and internal carotid artery occlusion (ICAO). METHODS: Case report. RESULTS: A 36-year-old man presented with sudden vision loss of only the left eye without any signs or symptoms of brain diseases. Fluorescein fundus angiography (FFA) showed left BRAO, and computed tomography angiography (CTA) of the head and neck showed entire left CCAO and ICAO. The patient's left vertebral artery was anastomosed with the left occipital artery via the muscular branch, supplying blood retrogradely to the left external carotid artery. The right internal carotid artery compensated for blood supply to the left anterior cerebral artery and middle cerebral artery via anterior communication, and the left posterior communication artery compensated for blood supply to the left middle cerebral artery. CONCLUSIONS: To our knowledge, this study was the first to report a case of BRAO combined with congenital CCAO and ICAO with vision loss as the first symptom and proposed the importance of head and neck examination in retinal artery occlusion at the first visit to a doctor.

Presentations to eye emergency departments with flashes and floaters differ dependent on incident solar radiation.

AIM: The aim of this retrospective review was to analyse the frequency of patients presenting with flashes and/or floaters (F/F) on bright versus dark days to the eye emergency department of a tertiary referral hospital (the Mater Misericordiae University Hospital) over a 3-year period. The diagnostic and clinical outcomes of F/F presentations were also analysed. METHODS: This retrospective study assessed eye casualty attendances between January 2018 and December 2020. Solar irradiation (j/cm2) at ground level was retrieved from the records of Met Eireann (Irish National Meteorological Service) via their open access records. A review of electronic patient medical records using the in-house database patient centre was carried out of all patients who attended EED of during the study timeline on the 5 'brightest' and 5 'darkest' days of each year. RESULTS: Seven hundred forty patient presentations were analysed in total. Overall, 16% (n = 119) of all patients that attended EED during the timeframe of the study presented with F/F. One hundred six patients (89%) presented with floaters, 40 patients (34%) presented with flashing lights/photopsia, and 35 patients (29%) presented with both F/F. More patients presented to EED with F/F on bright days when compared with dark days (74 vs 45, p < 0.05). Eighty-nine percent of all patients with F/F presented with monocular floaters. There were more floater presentations during bright when compared with dark days (70 vs 36, p < 0.05). More patients were diagnosed with PVD on bright days when compared with those diagnosed with PVD on dark days (43vs 15, p < 0.05). More RDs were diagnosed on dark days compared with bright days (7 vs 3, p < 0.05). CONCLUSION: This study established that F/F presentations were more likely to present during bright days when compared with dark days. The diagnosis of PVD was more common during bright days, and RDs were diagnosed significantly more frequently on dark days. Although incident solar radiation was correlated with greater floaters/PVD presentation, causation is unlikely, and the duration of PVD may have been longer in patients presenting on bright days (i.e. pseudo-sudden symptoms).

Virtual triaging in an eye emergency department during the COVID-19 pandemic.

AIM: The aim of this audit was to assess the effect of new guidelines on virtual triage referrals to an Irish eye emergency department (EED) during the COVID-19 pandemic. METHODS: A retrospective phone triage referral and clinical note audit was performed to assess outcomes of phone triaging in October. Guidelines for phone triage were formulated with particular regard to what conditions should be seen in EED, treated over the phone or sent straight to outpatients clinic or minor procedures. A prospective phone triage referral and case note audit was then done to assess outcomes after introduction of the guidelines in November. RESULTS: A total of 1700 patients were referred to the eye emergency department, 861 in October and 839 in November. A total of 577 patients were triaged for in-person EED review in November, compared to 692 prior to implementation of guidelines (p < 0.05). The number of patients referred straight to outpatients (p < 0.05) and treated over the phone (p < 0.05) was also significantly increased. Ultimately, the number of conditions unnecessarily triaged to EED, as per the guidelines implemented, was significantly reduced (p < 0.05). CONCLUSION: This audit addressed the need to reduce footfall during the COVID-19 pandemic, identified suitable avenues of referrals for certain conditions, and demonstrated that these guidelines significantly reduced the number of patients presenting to EED with conditions amenable to phone review or clinic follow-up.

Acute orbital compartment syndrome due to traumatic hemorrhage: 4-year case series and relevant literature review with emphasis on its management.

PURPOSE: Blindness in craniomaxillofacial (CMF) injuries may occur due to acute orbital compartment syndrome (AOCS). Primarily, this article aimed to retrospectively review our 4-year experience in the management of patients diagnosed with AOCS secondary to an orbital hematoma (OH). Furthermore, this paper included up-to-date information regarding the prevalence, diagnosis, management, and prognosis of AOCS. MATERIALS AND METHODS: We retrospectively screened the medical records of patients who visited our hospital's emergency department (ED) and were examined by an oromaxillofacial surgeon for CMF injuries, between September 1, 2013, and September 31, 2017. The electronic hospital's database was searched to retrieve all cases of CMF trauma admitted or referred to our clinic during this period. RESULTS: Over a 49-month period, 3,514 patients were managed for CMF injuries in ED; 9 cases (0.26%) were attributed to OCS caused by an OH. This group comprised 5 males and 4 females aged between 32 and 91 years old (mean 65.7, median 70). Seven out of 9 patients were subjected to lateral canthotomy and inferior cantholysis (LCIC), whereas septolysis was applied in 6 of them. Sight was preserved in 3 out of 8 patients (37.5%), since a patient died from a serious intracranial injury. Seven out of 9 patients (77.7%) of the OCS group had a history of hypocoagulable state. CONCLUSIONS: LCIC, septolysis, and careful dissection within inferotemporal orbital quadrant constitute a reliable approach for emergent orbital decompression. CT scan offers differential diagnosis of acute traumatic proptosis, but it should preferably follow LCIC. In case of OHs without pupillary abnormalities and/or impairment of visual acuity, close monitoring allowing for timely interventions is highly recommended to patients with a history of hypocoagulative status, (uncontrolled or severe) hypertension, head trauma, and decreased level of consciousness or in elderly patients suffering from dementia or without rapid access to follow-up medical care. Clinicians dealing with ED services must maintain high skills in AOCS diagnosis and in LCIC execution.

The Impact of the COVID-19 Pandemic on Emergency Department Visits Resulting in Ophthalmology Consultations.

Introduction The aim of this study is to determine the characteristics of eye-related emergency department (ED) visits resulting in ophthalmology consultation during the COVID-19 pandemic and compare them against an equivalent period from the previous year. Methods In this study, we reviewed the charts of patients who were admitted to ED with ocular complaints between March 11th, 2020 (the date of the first COVID-positive case in our country) and March 11th, 2021 (Study period 1; SP1) and those who were admitted to ED within the equivalent period of the previous year (Study period 2; SP2). The frequency of eye-related cases, the urgency status of complaints, diagnosis, treatment applied, and hospitalization status of the patients were compared. Results The proportion of ophthalmology consultations among all medical departments decreased from 4.52% to 4.04% (p<0.001). There was a 40.5% reduction in eye-related ED admissions during the pandemic, and the top three ocular diagnoses were foreign bodies of the ocular surface (24.3%), corneal abrasion (18.7%), and blow-out fractures (6.2%) during SP1. The proportion of urgent eye-related emergency visits increased during the pandemic year (80.7% of total cases) compared to the year prior to the pandemic (66.0% of total cases) (p<0.001). Although the number of ophthalmology consultations per day decreased during lockdown periods, this decrease was not statistically significant. Conclusion During the first year of the COVID-19 pandemic, the number of eye-related ED visits decreased in comparison to the year which preceded the pandemic. However, the proportion of urgent visits increased during the pandemic. Understanding the circumstances under which patients seek eye care in EDs is critical to rendering the optimal level of service of available resources.

Impact of Covid-19 pandemic on Ophthalmic Emergency Department in an Italian tertiary eye centre.

PURPOSE: To evaluate the effects of the COVID-19 pandemic on the Ophthalmic Emergency Department (OED) activity of the tertiary eye centre of Verona. METHODS: OED reports of patients visited during lockdown (COVID-period) and in the corresponding period of 2017, 2018 and 2019 (COVID-free period) have been retrieved to draw a comparison. Patients' demographic and clinical data recorded and analysed are the following: age, gender, previous ocular history, aetiology, symptoms onset, type of symptoms, discharge diagnosis, urgency and severity of diagnosis. RESULTS: OED consultations dropped from 20.6 ± 7.3 visits/day of the COVID-free period to 8.6 ± 4.6 visits/day of the COVID-period. In the COVID-period patients waited longer before physically going to the OED, lamented more vision loss and less redness and reported a higher percentage of traumatic events when compared to the COVID-free period. A significant reduction of ocular surface conditions occurred, while vitreo-retinal disorders increased. Overall, both urgency and severity of diagnosed diseases raised significantly in the COVID-period. CONCLUSION: The COVID-19 pandemic drove a significant reduction of the overall OED activity. People with less urgent and milder conditions preferred to wait and endure their ocular discomfort for a few days rather than leaving home and risking to contract the infection. Our analysis highlights how several times the OED is used improperly by patients diagnosed with non-urgent disorders. A more accurate use of the OED would allow a reduction of management costs and the avoidance of overcrowding, which can lead to delays in the care of patients that really need assistance.

Impact of lockdown during the COVID-19 outbreak on ophthalmological emergencies in a referral center in France.

PURPOSE: In March 2020, the sudden rise in the number of SARS-CoV-2 infections in France led the government to impose a strict lockdown during which all non-urgent medical consultations were postponed. From March 17 to May 10, 2020, private medical practices were closed, and telemedicine was encouraged. The consequences on ophthalmic care were dramatic, with over 90% of scheduled consultations canceled. The goal of this study was to describe consultations during the 2-month strict lockdown in Paris and to analyze its impact on the visual outcomes of patients consulting in the ophthalmology emergency department (OED). METHODS: Data of patients who presented to the OED of the A. de Rothschild Foundation Hospital (RFH), a tertiary ophthalmology center in Paris, France, during the lockdown period and its immediate aftermath were analyzed. The results were compared to the same time periods in the years 2018 and 2019. Four time periods were defined and numbered chronologically: March 17 to May 10, 2018 (period 1); March 17 to May 10, 2019 (period 2); March 17 to May 10, 2020 (period 3, the lockdown period); May 11 to June 9, 2020 (period 4, the post-lockdown period). RESULTS: The number of consultations was reduced by more than 50% during the lockdown period (n=2909 patients) and by 30% during the post-lockdown period (n=2622) when compared to periods 1 (n=7125) and 2 (n=8058). Even though LP4 saw an increase in the number of patients consulting, there was no increase in the rate of severe diseases (12.8% during LP3 vs. 11.1% during LP4), and the proportion of patients who were admitted was statistically similar (4.3% vs. 3.6%). Neuro-ophthalmic diseases were the most common during LP3 and LP4. Neovascular glaucoma was twice as common during post-LP4 (P=0.08). We noted a significant increase in patients with graft rejection consulting in our OED during the post-LP4 (P<0.001). These results were likely related to a delay in follow-up consultations due to the lockdown measures. CONCLUSION: The reduction in the number of consultations in our OED during the lockdown period affected both minor emergencies and severe ophthalmic diseases, but with no significant delay in diagnosis. More longitudinal and longer study is needed to confirm this and to retrospectively analyze the effects of the COVID-19 outbreak and lockdown.

COVID-19 pandemic and lockdown: Changing trends in Ophthalmology for in-patient and emergency services.

PURPOSE: The aim of this study was to evaluate the changing trends in terms of patient load, presenting complaints, surgical procedures and resource utilization in a multispeciality tertiary care hospital after lockdown due to COVID-19. METHODS: Retrospective.data were collected from Ophthalmology in-patient and emergency services of a government medical college and multispecialty tertiary care hospital in North India. Data pertaining to patient census, presenting complaints, surgical procedures and resource consumption were compared in the 6-month period (March 25 to September 30, 2020) following national lockdown and subsequent gradual unlock to data of same time period last year. RESULTS: A total of 1152 new patients visited Ophthalmology emergency service, whereas 324 sought tele-ophthalmology consultation.Majority were males (61.8%, n = 712), whereas average age of presentation was 34 ± 7.2 years. The number.of patients seeking emergency ophthalmic care reduced by 23.9% in the current year, in-patient record reduced by 96.53% and number of surgeries reduced by 98.13%. Tele-ophthalmology services comprised 21.95% of the total patient load. Use of triple layered surgical masks increased by 85.7%, use of disposable gloves increased by 89.5% but interestingly the availability of chlorhexidine hand rub fell by 15.9%, in the current year compared to last year. CONCLUSION: COVID-19 pandemic and lockdown have reduced the number of patients visiting tertiary health care facility for ophthalmic care. As manpower and resource consumption has increased, smart management is needed to tackle the current scenario efficiently. Tele-ophthalmology must be promoted and we must understand the changing trends to plan for the future accordingly.

A Retrospective Study of Disparities in an Academic Ophthalmic Emergency Department.

Purpose Emergency medicine is a common access point to health care; disparities in this care by demographic characteristics, including race and ethnicity, may affect outcomes. The Massachusetts Eye and Ear (MEE) Emergency Department (ED) is a subspecialty emergency department; data from this site can be utilized to better understand social determinants of quality ophthalmic care. Design This is a retrospective cross sectional cohort study in the MEE ED examining patient visits from June 1, 2016 to June 30, 2019. Methods Using the electronic medical record system, all unique visits were identified between June 1, 2016 and June 30, 2019 (inclusive); patient demographics (sex, race, ethnicity [Hispanic vs. non-Hispanic], primary care provider [PCP] status, insurance type, zip code, primary language), date of visit, triage category and outcomes (final diagnosis, visit duration, and next visit at MEE within 3 months of the ED visit) were collected. Kaplan-Meier plots were used to visualize likelihood of follow-up visit to MEE for urgent patients based on demographics. Multivariate linear regression was used to examine factors affecting visit durations, as stratified by urgency, and Cox proportional hazards regression was used to establish hazard ratios for next visit to MEE. Results Of the 46,248 ophthalmology ED initial visits, only triage status, season of visit, out-of-state residency, Medicare coverage, and Medicaid coverage led to statistically significant differences in visit durations for urgent visits compared with the respective reference groups. Similar trends persisted within the non-urgent visit cohort for visit durations. Residency, insurance coverage, season of visit, race, PCP status, and sex were identified as statistically significant predictors of the likelihood of a follow-up visit. Conclusion Data from an ophthalmic emergency department suggest that demographic factors do impact patient visit duration and time to follow-up visit. These findings suggest a continued need for attention to social determinants of health and equitable care of patients within ophthalmology.

Recognising and managing retinal detachments.

Retinal detachments are a potentially sight-threatening ophthalmic emergency that may result in significant, irreversible vision loss. The risk of developing retinal detachment increases with advancing age, myopia and trauma. Pre-existing retinal degenerations can precipitate a pre-detachment symptomatic period of photopsia or floaters, allowing clinicians to intervene early and prevent detachments. Novel imaging techniques, such as spectral-domain optical coherence tomography, and well-established topographic modalities, such as B scan, can help to elucidate the type of detachment and any underlying causes, and help with surgical management. The overarching goal of treatment is to identify and seal all retinal holes, relieve vitreoretinal traction and prevent further recurrence. Prompt prophylactic retinopexy of retinal holes and tears is crucial in preventing retinal detachment, the main treatments of which are pars plana vitrectomy, tamponading agents and silicone scleral buckle.

Case of Orbital Compartment Syndrome Post Cardiac Arrest.

Orbital compartment syndrome (OCS) is a rare ophthalmic surgical emergency in the setting of increased intraocular pressure (IOP) Irreversible vision loss can occur without immediate surgical treatment consisting of lateral cantholysis. We present a case of acute OCS discovered after cardiopulmonary resuscitation (CPR) with subsequent immediate lateral canthotomy and notable decrease in IOP. This in part demonstrates the importance of recognizing the clinical signs of OCS with or without trauma in the emergency department in addition with preparedness to perform a vision-saving procedure. Diagnosis is clinical and early recognition is essential. Index of suspicion for OCS in cardiac arrest without signs or history of trauma would typically be low, however, given the case presented, it was important for it to be excluded once the return of spontaneous circulation (ROSC) was achieved.

Bilateral hemorrhagic proptosis due to an uncommon cause in ocular emergency.

A 19-year-old male patient presented to the ocular emergency services with sudden onset of proptosis, pain, and bloody discharge. Further evaluation revealed bilateral visual acuity of finger counting close to face vision with an accurate projection of rays. Computed tomography scan of the head and orbit revealed diffuse orbital hemorrhage (mainly along the ocular coats) in the absence of any subperiosteal or intracranial hemorrhage. A complete hematological workup was done and it revealed decreased factor IX levels (9% of normal) consistent with hemophilia B (Christmas disease). The patient was managed medically with factor IX supplementation. At the end of 6 weeks, patient's visual acuity improved to 20/20 in both the eyes.

Utilization of Ophthalmology-Specific Emergency Department Services.

OBJECTIVE: To describe utilization trends of an ophthalmology-specific emergency department (ED). METHODS: Prospective cohort study of new patients presenting in the ophthalmology ED for at least a 30-day period in the spring of each year for five consecutive years (2010-14) at a university referral center. A data form, including information about the ED visit and patient demographics, was included in each patient chart. Data were analyzed with Pearson chi-square test and multiple logistic regression. RESULTS: A total of 5323 chart data forms were completed. An average of 42.2 new patients per day presented to the ophthalmology ED. Most common diagnoses were viral conjunctivitis (8.7%), dry eye syndrome (6.6%), and corneal abrasion (6.6%). Non-emergent visits accounted for 35.8% of surveys completed. Factors associated with non-emergent visits included female gender, age 65 years or older, weekday visits, and patient symptom duration greater than one week (p < 0.0001 for each factor). When compared to all other insurance categories combined, patients who were members of the regional public assistance program were the most likely to present with a non-emergency (48.5% versus 34.9%, p < 0.001), while Workers' Compensation patients were least likely to present with a non-emergency (16% versus 36.5%, p < 0.001). CONCLUSIONS: Over one-third of new patient visits were non-emergent. Factors predictive of non-emergent patient visits were female gender, age 65 years or older, duration of symptoms greater than one week, weekday visits, and the form of insurance coverage.

Optic Neuropathy Secondary to Polyarteritis Nodosa, Case Report, and Diagnostic Challenges.

PURPOSE: To describe a case of optic neuropathy as a primary manifestation of polyarteritis nodosa (PAN) and discuss diagnostic challenges. METHODS: Case report. RESULTS: A 41-year-old Hispanic man presented with a 2-day history of reduced visual acuity in his left eye. Physical examination revealed a complete visual field loss in the affected eye. Best-corrected visual acuity (BCVA) in the left eye was hand motion, and fundus examination revealed a hyperemic optic disk with blurred margins, swelling, retinal folds, dilated veins, and normal size arteries. BCVA in the right eye was 20/20; no anomalies were seen during examination of the fundus. The patient was started on oral corticosteroids and once the diagnosis of PAN was made, cyclophosphamide was added to the treatment regimen. Six months later, the patient recovered his BCVA to 20/20 in his left eye. CONCLUSION: Rarely does optic neuropathy present as a primary manifestation of PAN; nevertheless, it represents an ophthalmologic emergency that requires expeditious anti-inflammatory and immunosuppressive treatment to decrease the probability of permanent visual damage. Unfortunately, diagnosing PAN is challenging as it necessitates a high index of suspicion. In young male patients who present for the first time with diminished visual acuity, ophthalmologists become cornerstones in the suspicion of this diagnosis and should be responsible for continuing the study until a diagnosis is reached to ensure rapid commencement of immunosuppressive treatment.

Acute angle closure glaucoma - A potential blind spot in critical care.

We report a case of a 69-year-old gentleman who developed an acutely painful eye with loss of visual acuity whilst on the critical care unit. He was admitted three days previously with an infective exacerbation of chronic obstructive pulmonary disease requiring invasive mechanical ventilation. In addition, he received intravenous antibiotics, steroids, nebulised bronchodilators and intravenous aminophylline, together with noradrenaline for blood pressure support. On development of visual symptoms, an emergency ophthalmology review diagnosed acute angle closure glaucoma. Treatment with pilocarpine eye drops, intravenous acetazolamide and bilateral YAG laser iridotomies provided immediate symptom relief and he went on to make an excellent recovery. Acute angle closure glaucoma is a potentially devastating ophthalmic emergency. Critical care patients are at particular risk for the development of this condition due to the use of predisposing medications, such as sympathomimetics and beta agonists. Sedated patients also run a risk of delayed diagnosis so a high index of suspicion is required.