Pick ‘n’ Mix Week 3 March 2023

Estimated Reading Time: 5 minutes

We are really grateful to Trudie Pestell for sharing Pick ‘n’ Mix: a fabulous education initiative that she has been producing for University Hospital Southampton Emergency Department.

Each week we will bring you some clinical pearls to add to your knowledge and understanding with links to other resources as well as an OSCE of the week.


A 55 year old female presents to the ED with a red eye. It came on suddenly and the pain is severe and worsening. She has a headache, nausea, and vomiting and complains of not being able to see as well as usual. On examination, her cornea looks hazy and her globe is hard to palpation


Primary closed-angle glaucoma occurs with a reduction in the angle between the iris and the cornea, impairing aqueous humor drainage, and resulting in raised intraocular pressure. The raised pressure ultimately damages the optic nerve and can cause disc changes (cupping and pallor). In secondary closed-angle glaucoma, the reduced angle can be caused by chronic anterior uveitis or lens subluxation.


  • Semi-prone positioning
  • Screentime in a dark room
  • Adrenergic medications – adrenaline given in anaphylaxis
  • Antimuscarinic medicatons (such as tricyclic antidepressants)

Risk Factors

  • Increasing age
  • Female
  • Asian background
  • Family history
  • Hyperopia (farsightedness)

Investigations – Early suspicion is key – this is a sight-threatening diagnosis

  • Gonioscopy
  • Slit lamp examination


  • Lie the patient face up, and flat (no pillows)
  • Symptomatic relief – analgesia and antiemetics
  • Pilocarpine (a cholinergic agonist)
  • Azetozolamide (reducing the production of aqueous humor)
  • Definitive management – Laser iridotomy

The case of the breathless traveller

The beginning:

A 42-year-old lady comes to the Emergency Department feeling generally unwell and lethargic. She has recently returned from India and has developed a new cough and fever. Sometimes she coughs so much, blood comes up. As part of your workup, you perform a CXR

Miliary Tuberculosis – Named as it has lesions ‘resembling millet seed’ this is a form of TB where there is haematological dissemination from focal infection into the blood resulting in the seeding of other areas of the lungs and multiple organs with TB bacilli.

More information is available on the excellent Life in the Fast Lane

OSCE of the Week – Ophthalmological Examination

Brief history
General inspection
Visual acuity
Visual fields
Eye movements

Additional resources

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.