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Recently at the EM Core we discussed headache and the red eye.

I had a great case just over a week ago. A patient was triaged with headache and cataract.

On examination he had a very painful right eye, which was causing the headache. He could only see outlines of my fingers…..He had been like this for one week.

Here is a picture of his eye. What do you think?

Headache and eye pain

He had a ciliary flush(although not a huge one.

He had a cloudy cornea.

Visual acuity is decreased.

Pupil was not reactive.

On fluorescein staining, there was nothing to see.

He had ‘compartment syndrome of the eye’ – angle closure glaucoma.

The definitive diagnosis is made by taking pressures. This also differentiates it from keratitis.

Firstly we had trouble calibrating the ‘tono-pen’, then couldn’t measure a pressure with it. Then the penny dropped. I measured the pressure in the good eye and it was 11. The pen wasn’t measuring pressure as it was too high.


Next to treatment – acetazolamide 500mg IV, Timolol eye drops and alphagan eye drops, then transfer for definitive treatment under ophthalmology.


  • Dr Talina Vizard says:

    Great story great pictures. Thankyou

  • Dr.Mohd.S.Jalal says:

    very important subject. Another point to be mentioned for management especially in the Rural setting where an ophthalmologist is not available, is how to do corneal indentation using a cotton stick as a last resort to decrease the IOP until ophthalmologist care is available.

  • pat naidoo says:

    great case and shows how the “headtie” differential can be used to make a diagnosis.

    Thanks again

  • Dr Eva Wydymus says:

    My first thought was Acute Glaucoma but the clouded cornea somewhat put me off. It looked like an ulcer from the distance. Thank God for Fluorescein.
    Good story. I like the twist with ‘tono-pen’.

  • Michael Thomas says:

    Love the triage diagnosis, ‘headache and cataract’.

    This is a spot diagnosis of acute glaucoma if I ever saw one.

    Would be funny to compile a sample of triage pearlers, for publication in a discrete place (ie on the internet), as I’ve seen some crackers over the past couple of years.

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