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Key Features

  • Primary acute angle-closure glaucoma occurs in eyes with narrow anterior chamber angles, for which precipitating factors are

    • Shallow anterior chamber, which may be associated with farsightedness and short stature

    • Age (owing to enlargement of the crystalline lens)

    • Inheritance, being particularly prevalent among Inuits and Asians

  • May be precipitated by

    • Pupillary dilation from sitting in the dark

    • Stress

    • Pharmacologic mydriasis for ophthalmologic examination (rarely)

    • Medications with anticholinergic or sympathomimetic activity

  • Subacute primary angle-closure glaucoma may present as recurrent headache

  • Secondary acute angle-closure glaucoma may occur in uveitis

Clinical Findings

  • Extreme ocular pain

  • Blurred vision, typically with halos around lights

  • Nausea and vomiting

  • The eye is red and the cornea is cloudy, usually with a moderately dilated, nonreactive pupil

  • Intraocular pressure usually over 50 mm Hg, producing hard eye on palpation

Diagnosis

  • Markedly elevated intraocular pressure with shallow anterior chamber in both eyes

  • Must be differentiated from conjunctivitis, acute uveitis, and corneal disorders

Treatment

  • Immediate evaluation and treatment by an ophthalmologist are essential

  • A single 500-mg intravenous dose of acetazolamide, followed by 250 mg orally four times a day, together with topical medications is usually sufficient to lower intraocular pressure

  • If no response to acetazolamide, consider 1–2 g/kg of an osmotic diuretic, such as oral glycerin, intravenous mannitol, or intravenous urea

  • After intraocular pressure is reduced, topical 4% pilocarpine, 1 drop every 15 min for 1 h then four times a day, is used to reverse the angle closure

  • Definitive treatment is generally laser peripheral iridotomy or surgical peripheral iridectomy

  • If it is not possible to control the intraocular pressure medically, the angle closure may be overcome by

    • Corneal indentation

    • Laser treatment (argon laser peripheral iridoplasty)

    • Cyclodiode laser treatment

    • Paracentesis

    • Glaucoma drainage surgery

  • All patients with primary acute angle closure should undergo prophylactic laser peripheral iridotomy to the unaffected eye, unless that eye has already undergone cataract or glaucoma surgery

  • Whether prophylactic laser peripheral iridotomy should be undertaken in asymptomatic patients with narrow anterior chamber angles is mainly influenced by the risk of the more common chronic angle closure

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