GUIRITAN, ABIGAYLE THERESE R.

AUTONOMICS
2MEDB SUBSEC 5
2015

SGD
SEPTEMBER 5,

CASE:
A 72 year old male patient was admitted to the emergency room because of eye
pain, blurring of vision, and difficulty in depth perception. Review of systems
revealed that the patient has narrow- angle glaucoma. Review of current
medications revealed that the patient has colds for which the patient was
prescribed a nasal decongestant, oral phenylephrine at the outpatient department.
1. What is the patients chief complaint? What could be its cause?
Chief complaint: eye pain, blurring of vision, and difficulty
in depth perception
Cause: prescription of oral phenylephrine for the nasal
congestion of the patient.
PHENYLEPHRINE
-

DRUG CLASS
o Alpha adrenergic agonist
o Nasal decongestant
o Opthalmic vasoconstrictor or mydriatic
o Sympathomimetic amine
o Vasopressor
MECHANISM OF ACTION:
o Powerful postsynaptic alpha-adrenergic receptor stimulant that causes
vasoconstriction and increased systolic and diastolic BP with little
effect on the beta receptors of the heart. Topical application causes
vasoconstriction of the mucous membranes, which in turn relieves
pressure and promotes drainage of the nasal passages. Topical
ophthalmic application causes contraction of the dilator muscles of the
pupil (mydriasis), vasoconstriction, and increase outflow of aqueous
humor.
2. What autonomic receptor is affected by the nasal decongestant?
Alpha adrenergic receptor; selective alpha 1 agonist
3. What is the relationship of the drug phenylephrine to the patients chief
complaint? Is it preventable?
Sympathomimetic agents can induce transient mydriasis via stimulation of
alpha-1 adrenergic receptors. In patients with anatomically narrow angles or
narrow-angle glaucoma, pupillary dilation can provoke an acute attack. In
patients with other forms of glaucoma, mydriasis may occasionally increase

intraocular pressure. Therapy with sympathomimetic agents should be

administered cautiously in patients with or predisposed to glaucoma, particularly
-

narrow-angle glaucoma.
Phenylephrine causes simultaneous contraction of the sphincter and dilator
muscles of the iris in opposite directions pupil- block angle closure triggers
an IOP in an at risk eye
4. What other systemic symptoms might the patient experience?

Systemic administration:
CNS: Fear, anxiety, tenseness, restlessness, headache, light-headedness, dizziness,
drowsiness, tremor, insomnia, hallucinations, psychological disturbances, seizures,
CNS depression, weakness, blurred vision, ocular irritation, tearing, photophobia,
symptoms of paranoid schizophrenia
CV: Cardiac arrhythmias
GI: Nausea, vomiting, anorexia
GU: Constriction of renal blood vessels and decreased urine formation (initial
parenteral administration), dysuria, vesical sphincter spasm resulting in difficult and
painful urination, urinary retention in males with prostatism
5. What must be done in this patient?
Prehospital care:
The patient should be brought to the hospital in an expeditious manner to have the
IOP reduced. The px should remain in a supine position as long as possible (to
prevent further increase of IOP).
Emergency department care:
Medications must be given to reverse the effects of the drug phenylephrine that
caused his narrow angle glaucoma.
6. What medication(s) may be given to alleviate the patients symptoms?
Acetazolamide
a. Antiglaucoma drug
b. MOA- inhibits the enzyme carbonic anhydrase. This action decreases
AH formation in the eye( IOP)
Analgesic
c. For pain (extraocular manifestation); this can drastically increase an
already elevated IOP.
Pilocarpine
d. Parasympathomimetic drug
e. Miotic that leads to the opening of the angle.
Hyperosmotic agent (Mannitol)

f.

Creates an osmotic gradient in the eye between plasma and ocular

fluids IOP

Narrow
angle
glaucoma
(Closed angle glaucoma)
-

acute angle closure is defined

as at least 2 of the following
symptoms:
ocular
pain,
nausea/vomiting, and a history
of intermittent blurring of
vision with halos; and at least 3
of the following signs: IOP
greater than 21 mm Hg,
conjunctival injection, corneal
epithelial edema, mid-dilated
nonreactive
pupil,
and
shallower chamber in the
presence of occlusion.
Formation
of
adhesions
between the iris and trabecular
meshwork IOP symptoms
of pain, redness, and reduced
vision
Normal anterior chamber angle
anatomy: the trabecular meshwork
(TM) is found at the angle between
the iris and the cornea, and
constitutes the main drainage
structure that removes aqueous
humour (AH) from the eye. AH is
produced by the ciliary body (CB),
passing through the space between
the iris and the lens into the anterior
chamber, finally draining out of the
eye from the TM.
In pupil-block angle closure, AH is
unable to pass through the anterior chamber due to the pupillary sphincter being adherent to
the anterior lens. A positive force in the posterior chamber due to AH build-up leads to a rise
in IOP, and blockage of the TM and anterior chamber angle