What is the emergent condition to rule out in a patient with blurry vision and a sensation of a foreign body in the eye?

Acute Angle-Closure Crisis (AACC)

The emergent condition to rule out in a patient presenting with blurry vision and foreign body sensation is acute angle-closure crisis (AACC), a sight-threatening emergency that can cause permanent vision loss or blindness if untreated. 1

Why AACC is the Critical Emergency

While foreign body sensation can result from benign causes like corneal abrasion 2, the combination with blurry vision raises immediate concern for AACC, which presents with:

• Pressure-induced corneal edema experienced as blurred vision 1
• Foreign body sensation (though more commonly described as severe eye pain) 3
• Mid-dilated, poorly reactive or nonreactive pupil 1
• Conjunctival and episcleral hyperemia (red eye) 1
• Headache, nausea, and vomiting 1
• Halos around lights 1

Devastating Consequences of Missed Diagnosis

Untreated AACC leads to rapid glaucomatous optic neuropathy with high rates of permanent visual disability: 1

• 18% of eyes become blind (50% of blindness from glaucoma itself) 1
• 58% develop visual acuity worse than 20/40 1
• Progressive vision loss may result in bilateral blindness 1
• The fellow eye is at high risk for AACC as well 1

Essential Immediate Examination Components

When AACC is suspected, perform these specific assessments immediately: 1

Pupil Examination

• Check for mid-dilated, asymmetric, or oval pupil in the affected eye 1
• Assess reactivity (may be poor or nonreactive) 1
• Look for relative afferent pupillary defect 1

Slit-Lamp Biomicroscopy

• Conjunctival hyperemia 1
• Shallow central and peripheral anterior chamber depth 1
• Corneal microcystic and stromal edema 1
• Anterior chamber inflammation 1

Intraocular Pressure (IOP)

• Measure IOP in both eyes—rapidly elevated IOP confirms AACC 1, 3
• IOP can rise to very high levels when the anterior chamber angle is suddenly obstructed 1

Gonioscopy

• Essential to visualize iridotrabecular contact and confirm angle closure 1
• Should be performed when IOP is controlled 1

Critical History Elements

Ask specifically about: 1

• Previous episodes of blurred vision, halos around lights, eye pain, headache, or eye redness (suggesting intermittent angle closure) 1
• Family history of acute angle-closure glaucoma 1
• Medications that precipitate angle closure: 1, 4, 5
  • Anticholinergics (including over-the-counter products containing belladonna) 5
  • Sympathomimetics and beta-agonists (especially in critical care settings) 4
  • Sulfonamides and topiramate 1
  • Inhaled ipratropium bromide and salbutamol 1
• Hyperopia (farsightedness)—hyperopic eyes have narrower angles and increased AACC risk 1

Common Pitfall to Avoid

Do not dismiss blurry vision with foreign body sensation as simple corneal abrasion without measuring IOP and assessing the anterior chamber depth. 3 The foreign body sensation in AACC may be less prominent than the severe pain typically described, but the blurred vision from corneal edema is a key distinguishing feature. 1

Immediate Management When AACC is Confirmed

Initiate treatment immediately upon high clinical suspicion—do not delay for confirmatory testing: 3

• Systemic ocular hypotensive therapy to prevent optic nerve damage 3
• Topical medications (parasympathomimetics like pilocarpine, beta-blockers, carbonic anhydrase inhibitors, alpha-2 agonists) 6
• Systemic carbonic anhydrase inhibitors (acetazolamide) and osmotic agents (mannitol) 6, 4
• Urgent ophthalmology referral for definitive laser peripheral iridotomy 3, 4