The correct answer is C. This patient has angle closure or acute glaucoma. These patients often have unilateral headaches from referred pain in the distribution of the ophthalmic division of the trigeminal nerve. They experience blurry vision from corneal edema. Perhaps the most important clinical sign is a mid-dilated fixed pupil in the context of a red eye and headache. Most patients also complain of ocular pain. In acute glaucoma, the optic nerve often appears normal, unlike chronic open angle glaucoma where cupping and pallor of the nerve are present. This patient was also recently placed on a tricyclic antidepressant that has anticholinergic effects, promoting dilation of the pupil and placing the patient at increased risk for angle closure glaucoma. Urgent ophthalmic consultation is indicated for the treatment of this patient.
A migraine headache is not the right diagnosis. Although this patient does have a unilateral headache, visual disturbance, nausea, and vomiting, a migraine headache would not be responsible for a fixed mid-dilated pupil. Treatment with antimigraine therapy (choice A) would not be indicated.
Depression would not cause the clinical signs presented above. Attributing this presentation to depression (choice B) would miss the diagnosis and potentially cost this patient her vision.
An MRI of the brain and orbits (choice D) would not be helpful in angle closure glaucoma.
An investigation for syphilis (choice E) is not likely to be positive. An Argyll-Robertson pupil is one that accommodates to near but does not react to light. This is a chronic finding of tertiary neurosyphilis. The optic nerve would demonstrate pallor.
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