# A nurse is assessing a 72-year-old client with suspected acute angle-closure glaucoma who presents with severe eye pain, nausea, and reports seeing halos around lights. Which assessment finding would be the most critical indicator requiring immediate intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541563 > language: ko > subject: Adult Health ## 문제 A nurse is assessing a 72-year-old client with suspected acute angle-closure glaucoma who presents with severe eye pain, nausea, and reports seeing halos around lights. Which assessment finding would be the most critical indicator requiring immediate intervention? The nurse observes that the client has severe eye pain, nausea, and reports seeing halos around lights. ## 보기 1. Intraocular pressure of 45 mmHg with a hard, fixed pupil **✔ 정답** 2. Mild peripheral vision loss with gradual onset 3. Eye redness with moderate discomfort during blinking 4. Slightly elevated intraocular pressure of 22 mmHg **정답: 1** ## 해설 Intraocular pressure of 45 mmHg with a hard, fixed pupil is the most critical finding in acute angle-closure glaucoma, indicating severe pressure elevation requiring emergency intervention. Other options represent less urgent or chronic findings. ## 심화 해설 Understanding the Clinical Emergency The assessment findings of severe eye pain, nausea, and halos around lights in a 72-year-old client are classic indicators of acute angle-closure glaucoma (AACG). This condition is a true ophthalmological emergency where the drainage angle of the eye becomes suddenly blocked, preventing aqueous humor outflow [1]. The resulting rapid and extreme elevation in intraocular pressure (IOP) can cause irreversible optic nerve damage and permanent vision loss if not treated immediately [1]. Analysis of Assessment Findings The correct answer is the finding of an intraocular pressure (IOP) of 45 mmHg with a hard, fixed pupil. To understand why, let's analyze the pathophysiology and clinical data: - Markedly Elevated IOP: A normal IOP ranges from 10 to 21 mmHg. A pressure of 45 mmHg is critically high and represents a state of severely compromised ocular perfusion. Case reports and studies on AACG consistently describe IOPs in this range during acute attacks, with some documented as high as 59 mmHg or even exceeding 60 mmHg [3,4]. At this pressure, the optic nerve is under immediate threat [1]. - Hard, Fixed Pupil: The extreme pressure causes ischemia to the iris sphincter muscle, paralyzing it. This results in a mid-dilated, non-reactive ("fixed") pupil that feels "hard" or "rock-hard" to palpation compared to the normal eye. This is a direct mechanical consequence of the pressure spike and a hallmark physical exam finding for AACG. - Correlation with Symptoms: The patient's report of "halos around lights" is explained by corneal epithelial edema caused by the high IOP forcing fluid into the cornea. The severe pain and nausea are a vagal response to the sudden, intense pressure elevation [1,3]. Why the Other Options Are Less Critical - Option 2 (Mild peripheral vision loss with gradual onset): This finding is more characteristic of chronic primary open-angle glaucoma (POAG). In POAG, the drainage angle is open but dysfunctional, leading to a slow, insidious rise in IOP over months to years. While serious, it does not represent the same minute-to-minute threat of irreversible damage as an acute angle-closure crisis. - Option 3 (Eye redness with moderate discomfort during blinking): These are non-specific signs that can be present in many less urgent conditions, such as conjunctivitis or dry eye syndrome. While eye redness is a symptom of AACG, the combination of "moderate discomfort" and the absence of a critically high IOP or a fixed pupil makes this a much lower priority [1]. - Option 4 (Slightly elevated intraocular pressure of 22 mmHg): An IOP of 22 mmHg is only marginally above the normal upper limit. This mild elevation, in the absence of other critical signs, is not indicative of an acute emergency. It might warrant further investigation for ocular hypertension or early glaucoma but does not demand the same immediate, aggressive intervention to prevent blindness. The Critical Link to Immediate Intervention The urgency of AACG is directly tied to the duration and magnitude of the IOP elevation. The markedly elevated IOP of 45 mmHg with a fixed pupil is the most critical indicator because it confirms the diagnosis of an acute attack and signals that the retina and optic nerve are actively suffering from ischemic damage [1]. This clinical picture triggers the immediate, time-sensitive interventions needed to lower the pressure, such as administering hyperosmotic agents, topical beta-blockers, and alpha-agonists, and preparing the client for emergency laser iridotomy to create an alternative pathway for aqueous humor drainage. The severity of the initial presentation, including the peak IOP, is directly correlated with the extent of angle closure and the urgency of the clinical situation .References (research sources) - [1]Acute Closed-Angle Glaucoma-an Ophthalmological Emergency.Research articleNüssle S, Reinhard T, Lübke J. (2021) · DOI: 10.3238/arztebl.m2021.0264 ## 임상 시나리오 Acute Angle-Closure Glaucoma CrisisImmediate Recognition and Intervention The classic triad of severe eye pain, nausea/vomiting, and halos around lights in an older adult is an emergency. The most critical assessment finding is an intraocular pressure (IOP) above 40 mmHg with a fixed, mid-dilated pupil that feels hard on palpation. A normal IOP is 10–21 mmHg. Pressures exceeding 30 mmHg rapidly compromise optic nerve perfusion. The elevated pressure causes iris ischemia, paralyzing the sphincter muscle and resulting in a non-reactive, "rock-hard" pupil. CautionDo not confuse with conjunctivitis or open-angle glaucoma. Gradual peripheral vision loss is not an emergency. An IOP of 22 mmHg is only slightly elevated and does not indicate an acute attack. Immediate ophthalmology referral is required to prevent permanent vision loss. ## 핵심 개념 - **Acute Angle-Closure Glaucoma (AACG)** — An ophthalmological emergency where sudden blockage of the eye's drainage angle causes a rapid, extreme rise in intraocular pressure, threatening vision. - **Intraocular Pressure (IOP)** — The fluid pressure inside the eye, normally ranging from 10 to 21 mmHg; critically high levels can cause irreversible optic nerve damage. - **Fixed, Dilated Pupil** — A pupil that is mid-dilated and non-reactive to light, caused by ischemia of the iris sphincter muscle due to extremely high intraocular pressure. ## 같은 주제 문제 - [A nurse is assessing a 68-year-old client who presents to the emergency department with se…](https://mymerci.kr/pages/nclex_q.php?qn_id=541561) - [A nurse is assessing a 68-year-old client diagnosed with primary open-angle glaucoma. 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