An Intraocular Pressure Of 98Mmhg

A male in his 90s with severe learning difficulties was referred to eye casualty by his GP with suspected left eye periorbital cellulitis. Care home staff reported that the patient was reluctant to open his eye and struck out at anyone who attempted examining him. POH included bilateral cataract surgery in 2022 for left eye phacomorphic glaucoma. PMH included colon cancer and he was under palliative care.

IOP was right 18 and left 98 mmHg. Examination revealed left-sided preseptal cellulitis, proptosis, haemorrhagic chemosis, 360^o corneal neovascularisation, corneal oedema, flat AC, inferior hyphaema, mid-dilated pupil. The IOL was densely brown-tinted. B-scan revealed a heterogeneous mass in the posterior segment.

Differentials for the mass included vitreous haemorrhage; suprachoroidal haemorrhage; choroidal melanoma; choroidal metastasis. The patient was commenced on IV broad-spectrum antibiotics, Acetazolamide and IOP-lowering drops, steroids, antibiotics, and Atropine. CT confirmed orbital cellulitis and excluded retrobulbar masses or haemorrhage.

Despite resolution of the cellulitis, IOP stayed between 95 to 99.

Following best-interest multi-disciplinary meetings, GA for interventions such as cyclodiode, retrobulbar alcohol or enucleation were deemed too hazardous; and these procedures under LA / sedation posed challenges to the patient and his eye due to his variable cognitive status and compliance. Topical treatments and high-dose oral opioids maintained his IOP at mid-50s and returned his eye to its baseline pain-free state.

This case records an extremely high IOP, which has not been previously reported in the literature. We highlights the complexities of managing a painful blind eye. It also highlighted the challenges faced by patients with learning difficulties such as more advanced disease at the time of assessment, lower rates of screening, delays in reaching a diagnosis, insufficiencies in communication and complex management choices. We explore RCOphth and Public Health England guidance on eye care for adults with learning difficulties.