Under Pressure? Take Their Blood Pressure

I always enjoy the Clinical Quandaries column and the February installment was no exception. In it, Dr. Williams gives a decent review of non-traumatic cranial nerve six palsies. She is correct in noting that 28% are caused by hypertension and 17% by diabetes. I was surprised when she did not recommend taking the patient’s blood pressure and doing a stat in-office A1C, the results of which would provide potential etiology for, and immediately dictate how, the patient should be treated, allowing the eye doctor to take control of the patient. I will point out that many patients, especially those with diabetes, are not forthcoming about their blood glucose level or medication use (or non-use). The results of these two tests can potentially save the patient an unnecessary visit to the emergency department.

If both the blood pressure and blood glucose are normal, the patient should be started on an 81mg coated aspirin, one per day (with no contraindications) and followed as Dr. Miller recommends.

If the blood pressure is elevated but not in stroke territory or the A1C is high, or both, the patient can be advised to see their primary care physician on an urgent basis to get these controlled. Start treatment with an 81mg asprin, as above. If the blood pressure is elevated and in “stroke territory” (diastolic 110mm Hg or greater) the patient should be transported to the emergency department. Inform the EMTs that your patient has a right (or left) sixth nerve palsy as a result of uncontrolled hypertension to help avoid confusion in the emergency department. Do not let this patient drive himself, for obvious reasons, and follow after blood pressure is controlled.

These patients are perfect examples of how an astute clinician and two of the simplest tests in medicine can prevent CVAs, blindness and even loss of life; they will be forever grateful.

 How to follow them is a story for another time.

  —Mark R. Flora, OD
General Eye Medicine, Disease & Injury
Atlantic Eye Associates

Comment from ‘Clinical Quandaries’ editor Paul Ajamian, OD: 

Dr. Flora,

Your detailed advice on handling these patients is very much appreciated. Often, in my experience, a presentation of double vision leads to panic and often a referral to the wrong source, either an ophthalmologist or neurologist. Our role in steering these patients to the correct medical specialist is critical. Thank you for taking the column (which serves as a brief review) a step further on a very important subject!

—Paul Ajamian, OD

Center Director, Omni Eye Services of Atlanta

Sight Gags By Scott Lee, OD