Article

Drug-induced visual impairment may be a manifestation of acute angle closure glaucoma

Visual impairment may be a “>prehospital settings, but it seems to constitute a promising research tool.

Hichem Chenaitia MD

Department of Emergency Medicine and Intensive Care

Timone University Hospital Marseille, 13005, France

E-mail address: [email protected]

Christian Squarcioni MD

Department of Neurological Intensive Care Timone University Hospital, Marseille, 13005, France

Brun Pierre Marie MD Querellou Emgan MD

Department of Emergency Medicine and Intensive Care Timone University Hospital, Marseille, 13005, France

Petrovic Tomislav MD Prehospital Emergency Medical Unit Avicenne Hospital, Bobigny, 93000, France

WINFOCUS (World Interactive Network Focused On Critical UltraSound) France Group

doi:10.1016/j.ajem.2011.06.025

References

  1. Petrovic T, Gamand P, Tazarourte K, Catineau J, Lapostolle F. Feasibility of transcranial Doppler ultrasound examination out-of- hospital. Resuscitation 2010;81(1):126-7.
  2. Holscher T, Schlachetzki F, Zimmermann M, Jakob W, Ittner KP, Haslberger J, et al. Transcranial ultrasound from diagnosis to early stroke treatment. 1. Feasibility of prehospital cerebrovascular assess- ment. Cerebrovasc Dis 2008;26(6):659-63.
  3. Maurer M, Shambal S, Berg D, Woydt M, Hofmann E, Georgiadis D, et al. Differentiation between intracerebral hemorrhage and ischemic stroke by transcranial color-coded duplex-sonography. Stroke 1998;29(12):2563-7.
  4. Behnke S, Becker G. sonographic imaging of the brain parenchyma. Eur J Ultrasound 2002;16(1-2):73-80.
  5. Zipper SG, Stolz E. Clinical application of transcranial colour-coded duplex sonography. Eur J Neurol 2002;9(1):1-8.

Drug-induced visual impairment may be a manifestation of acute angle closure glaucoma

To the Editor,

The patient who was reported as having become “hot, blind, and mad” [1] manifested some of the clinical features of the delirium syndrome, including risk factors such as preexisting dementia in association with sensory deprivation (the latter due to Blurred vision attributable to papillary dilatation) and precipitating factors such as pain (from the scalp laceration) and environmental change (the latter attributable to referral to the emergency department [ED]),

all 4 components being among the ones highlighted in a recent review of this syndrome [2]. The hidden danger is that, in the preoccupation with the management of the cognitive aspects of this syndrome, when the etiological agent is a drug that can cause pupillary dilatation (as may be the case with antihistamines) [1], clinicians may fail to recognize that acute angle closure glaucoma may supervene in those subjects who are predisposed to the latter complication because of having a shallow anterior chamber [3,4]. The same considerations apply to an elderly patient with or without a previous history of dementia who experiences pupillary dilatation because of the administration of nebulized ipratropium bromide for an acute exacerbation of Chronic obstructive airways disease. In this instance, pupillary dilatation occurs when nebulized vapor escapes from an ill-fitting mask, and the condensate diffuses through the cornea to cause mydriasis complicated, in patients with a shallow anterior chamber, by acute angle closure glaucoma [4]. An added twist is the risk of acute Urinary retention (itself a precipitant of Acute delirium) [2] if the elderly patient in question happens to have coexisting benign prostatic hypertrophy [5,6]. Although the latter complication may have a delayed onset, as was the case in 3 patients reported in the literature [6], it is worth noting that some patients who have nebulized bronchodilators pre- scribed for the first time in the ED may, subsequently, be discharged from ED on domiciliary nebulizer therapy, and it is among the so-called recent starters (of nebulized ipratropium bromide) that the risk of Acute urinary retention is highest (adjusted odds ratio, 3.11; 95% confidence interval, 1.21-7.98) [5]. To mitigate the risk of acute angle closure glaucoma, the oblique penlight illumination test has been proposed (with some caveats) to identify patients with a shallow anterior chamber [3]. A high index of suspicion for this disorder should be entertained in older patients, including those among them who are farsighted and those who wear “plus” glasses that magnify objects and those who belong to certain racial groups [3]. As a corollary, for men with a history suggestive of urinary outflow obstruction, “it might be advisable to consider alternatives for inhaled anticholinergic agents” [5], given that “in men with COPD and benign prostatic hyperplasia (BPH) the association (of acute urinary retention) was strongest (adjusted odds ratio 4.67; 95% confidence interval 1.56-14.0)” [5]. Where the patient fits into the “recent starter” category, domiciliary follow-up should include not only evaluation of symptoms of acute angle closure glaucoma but also evaluation of symptoms of urinary outflow obstruction.

Oscar M.P. Jolobe MB, ChB, DPhil

Manchester Medical Society c/o John Rylands University Library Oxford Road

M13 9PP Manchester, UK E-mail address: [email protected]

doi:10.1016/j.ajem.2011.06.039

References

  1. Ochs KL, et al. Hot, blind, and mad: avoidable geriatric anticholinergic delirium. Am J Emerg Med 2011doi:10.1016/j.ajem.2011.01.007.
  2. Marcantonio ER. Delirium. Ann Intern Med 2011 [ITC6-2 to ITC6-16].
  3. Razeghinejad MR, et al. Iatrogenic glaucoma secondary to medications. Am J Med 2011;124:20-5.
  4. Lachkar Y, et al. Drug-induced acute angle closure glaucoma. Curr Opin Ophthalmol 2007;18:129-33.
  5. Afonso ASM, Verhamme KMC, Stricker BHC, et al. Inhaled anticholin- ergic drugs and risk of acute urinary retention. BJU Int 2010;107:1265-72.
  6. Lozewicz S. Bladder outflow obstruction induced by ipratropium bromide. Postgrad Med J 1989;65:260-1.

Do you think about traumatic appendicitis in your trauma bay?

To the Editor,

We read with great interest the article by Charlotte Derr and D. Eliot Goldner “Posttraumatic appendicitis: further extending the extended Focused assessment with sonography in trauma examination,” which states that ultrasonography may have an unrealized potential as a diagnostic tool for traumatic appendicitis in the trauma bay [1].

“Too little emphasis and serious consideration has been devoted toward this condition, and we hope to underscore its existence and character.” This statement was published by Michael W. Shutkin and S. H. Wetzler in 1936 in an article in which they discussed about 4 cases of traumatic appendicitis [2]. However, the term traumatic appendicitis goes back to many years ago when Osler believed that “persons whose work necessitates the lifting of heavy weights seem more prone to the disease” [3].

Although before challenging with such a case, you may ask yourself whether this entity is really a fact or a fiction, but if you review the literature, you will find that several

cases of appendicitis after blunt abdominal trauma have been reported [1,4-6]. In our practice, we had 3 cases of traumatic appendicitis in our trauma center. All of them had a long appendix that seemed to be compressed against the iliac bone.

Indeed, we want to reemphasize that trauma surgeons and emergency medicine physicians should think about the possibility of traumatic appendicitis in their trauma bays.

Hamed Ghoddusi Johari MD Trauma Research Center General Surgery Department

Shiraz University of Medical Sciences

Shiraz, Iran E-mail address: [email protected]

Shima Eskandari MD

Trauma Research Center Shiraz University of Medical Sciences

Shiraz, Iran

doi:10.1016/j.ajem.2011.07.004

References

  1. Derr C, Goldner DE. Posttraumatic appendicitis: further extending the extended focused assessment with sonography in trauma examination. Am J Emerg Med 2009;27(5):632.e5-7.
  2. Shutkin MW, Wetzler SH. Traumatic appendicitis. Am J Surg 1936; 31(2):514-20.
  3. Osler WM. Practice of medicine3rd ed. ; 1899. p. 534.
  4. Ciftci AO, Tanyel FC, Buyukpamokcu N, et al. Appendicitis after blunt abdominal trauma: cause or coincidence? Eur J Pediatr Surg 1996;6(6): 350-3.
  5. Etensel B, Yazici M, Gursoy H, et al. The effect of blunt abdominal trauma on appendix vermiformis. Emerg Med J 2005;22:874-7.
  6. Ramsook C. Traumatic appendicitis: fact or fiction? Pediatr Emerg Care

2001;17(4):264-6.

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