What is the urgent evaluation and management for a 30-year-old woman presenting with nausea, vomiting, right eye pain, and swelling?

Urgent Ophthalmology Evaluation for Acute Angle-Closure Crisis

This 30-year-old woman presenting with right eye pain, swelling, nausea, and vomiting requires immediate ophthalmology evaluation for suspected acute angle-closure crisis (AACC), which is a vision-threatening emergency that can cause permanent blindness if not treated within hours.

Immediate Clinical Assessment

The constellation of unilateral eye pain with nausea and vomiting is a classic presentation for AACC 1. While this patient is younger than the typical demographic (older age is a risk factor), female gender itself is a significant risk factor for primary angle-closure disease 1.

Key examination findings to assess immediately:

• Visual acuity - any reduction indicates advanced crisis
• Pupil examination - look for a mid-dilated, poorly reactive pupil
• Corneal clarity - pressure-induced corneal edema causes haziness
• Conjunctival/episcleral injection - vascular congestion is characteristic
• Intraocular pressure - will be markedly elevated (often >40 mmHg)

The nausea and vomiting are systemic manifestations of the severely elevated intraocular pressure, not a separate gastrointestinal issue 1.

Differential Considerations

While AACC is the primary concern, other urgent conditions must be considered:

• Orbital cellulitis - would present with proptosis, restricted eye movements, and fever; less likely to cause nausea/vomiting 2
• Scleritis or anterior uveitis - severe photophobia would be prominent 2
• Infectious keratitis - requires contact lens use or trauma history 2

The presence of nausea and vomiting with eye pain strongly points toward AACC rather than these alternatives 1.

Immediate Management Algorithm

If AACC is confirmed:

1. Medical treatment to lower IOP acutely 1:

   • Aqueous suppressants (topical beta-blockers, alpha-agonists, carbonic anhydrase inhibitors)
   • Parasympathomimetics (pilocarpine to break pupillary block)
   • Osmotic agents (IV mannitol or oral glycerol) if IOP remains dangerously elevated

2. Definitive treatment 1:

   • Laser peripheral iridotomy or surgical iridectomy once IOP is controlled
   • This relieves the pupillary block mechanism

3. Prophylactic treatment of fellow eye 1:

   • Laser iridotomy in the unaffected left eye is essential, as risk of bilateral involvement is high

Critical Pitfalls to Avoid

• Do not attribute nausea/vomiting to gastroenteritis when accompanied by unilateral eye pain - this delays vision-saving treatment 1
• Do not dilate the pupil for fundoscopic examination if angle-closure is suspected - this worsens the crisis
• Time is vision - permanent optic nerve damage occurs within hours of untreated AACC
• Do not discharge without gonioscopy if any suspicion exists - dark-room dynamic gonioscopy is the gold standard for diagnosis 1

This patient requires same-day ophthalmology consultation, ideally within 1-2 hours, as AACC causes irreversible vision loss if treatment is delayed.