A 68-year-old woman who wears +4.00 diopter glasses for distance vision in both eyes. She consults because since a few weeks ago she has been having eye pain with headache and blurred vision at night when she is watching television in twilight. Which of the following pathologies is she most likely to present?
We are presented with a 68-year-old woman with moderate hyperopia and no history of cataract surgery. This is not a mere coincidence: the fact that the patient is hyperopic is important, because the eyeballs of hyperopic patients are shorter, with a certain conflict of space in the anterior segment when the crystalline lens undergoes a process of intumescence secondary to age (what patients call incipient cataract). In the clinical case, moreover, the ocular and headache pain occurs in scotopic situations, or in situations of dim ambient lighting, which produces an average mydriasis to optimize the light influx to the eyeball. It is evident, therefore, that the patient suffers from primary angular closure processes that possibly self-resolve when the triggering situation ceases, and not a true acute glaucoma attack. But these intermittent angular closures are contemplated within the spectrum of glaucoma due to primary angular closure (option 1 correct). Migraine, not being a Neurology question, can sometimes be a confounder in the usual clinic; however, patients are usually younger, or at least have a clear history of migraine, and, above all, they present symptomatologic worsening with intense sensory stimuli (photophobia and phonophobia), but symptoms are not worsened precisely in cases of dim lighting (option 2 incorrect). Actinic keratitis occurs precisely in patients exposed to ultraviolet radiation that is not properly filtered before reaching the cornea; it is typical of welders (it is called welder's keratitis), skiers and other people with very intense light exposures and without adequate eye protection (wrong option 3). Dry eye syndrome does not usually produce headache, and ocular discomfort does not go beyond the persistent discomfort that patients might define as pain because of its recently more studied neuropathic component. Some forms of dry eye may be worse in the evening but others are worse in the morning, and it depends mainly on the frequency of blinking. In addition, dry eye syndrome is an outdated term; nowadays it is preferred to speak of dry eye disease (incorrect option 4).
Glaucoma due to primary angular closure.
Migraine.
Actinic keratitis.
Dry eye syndrome.
It is evident, therefore, that the patient suffers from primary angular closure processes that possibly self-resolve when the triggering situation ceases, and not a true acute glaucoma attack. But these intermittent angular closures are contemplated within the spectrum of glaucoma due to primary angular closure (option 1 correct).
Migraine, not being a Neurology question, can sometimes be a confounder in the usual clinic; however, patients are usually younger, or at least have a clear history of migraine, and, above all, they present symptomatologic worsening with intense sensory stimuli (photophobia and phonophobia), but symptoms are not worsened precisely in cases of dim lighting (option 2 incorrect).
Actinic keratitis occurs precisely in patients exposed to ultraviolet radiation that is not properly filtered before reaching the cornea; it is typical of welders (it is called welder's keratitis), skiers and other people with very intense light exposures and without adequate eye protection (wrong option 3).
Dry eye syndrome does not usually produce headache, and ocular discomfort does not go beyond the persistent discomfort that patients might define as pain because of its recently more studied neuropathic component. Some forms of dry eye may be worse in the evening but others are worse in the morning, and it depends mainly on the frequency of blinking. In addition, dry eye syndrome is an outdated term; nowadays it is preferred to speak of dry eye disease (incorrect option 4).