Iatrogenic acute angle closure glaucoma masked by general anaesthesia and intensive care.

Acute angle closure glaucoma is a medical emergency which can result in blindness. As it is very painful patients are usually referred rapidly to an ophthalmologist. If it occurs following general anaesthesia however, the diagnosis may not be considered and symptoms such as pain and vomiting wrongly attributed. Delayed diagnosis puts the patient at risk both from the ocular complications of acute angle closure glaucoma, and also from inappropriate investigation and intervention. We report an illustrative case where bilateral acute angle closure glaucoma followed a general anaesthetic. The correct diagnosis was delayed for 11 days. CASE REPORT. A 66 year old lady underwent abdominal hysterectomy. During her general anaesthetic she was preoxygenated. Her intubation with an endotracheal tube was moderately difficult. The intravenous anaesthetic agents administered (in order of use) were; atropine, thiopentone, suxamethonium, vecuronium, cyclizine, neostigmine, doxapram and glycopyrrolate. There were no intra-operative complications but extubation was difficult. Immediately post-operatively she became hypoxic, as assessed by her oxygen saturation, and was reintubated and transferred to the Intensive Care Unit. The clinical impression at that time was that she had aspirated during surgery and developed left ventricular failure. A chest radiograph confirmed pulmonary oedema. She was ventilated for two days and during this time developed a pneumothorax following the insertion of a central venous line. This was successfully treated with the insertion of a chest drain. In the Intensive Care Unit she received intravenous frusemide, digoxin, amoxycillin and subcutaneous heparin. Clinically at this time she appeared to have developed a chest infection with the development of coarse crepitations at the lung bases, and to aid respiration nebulised solutions of ipratropium bromide and salbutamol were commenced. A subsequent chest radiograph showed lung fields to be clear and her pneumothorax to have resolved. She returned to the ward on the fourth postoperative day with nausea and vomiting. Her right eye was noted to be injected but she made no complaint of specific ocular discomfort. Her abdominal wound dehisced and was resutured under general anaesthetic. She made an uneventful recovery from this procedure. Over the following two days she received repeated doses of intramuscular pethidine and cyclizine for pain and nausea. She also continued to receive nebulised solutions of ipratropium bromide and salbutamol.