Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 7-10: Acute Angle-Closure Glaucoma + Key Features Download Section PDF Listen +++ +++ Essentials of Diagnosis ++ Older age group, particularly farsighted individuals Rapid onset of severe pain and profound visual loss with "halos around lights" Red eye, cloudy cornea, dilated pupil Hard eye on palpation +++ General Considerations +++ Primary acute angle-closure glaucoma ++ Results from closure of a preexisting narrow anterior chamber angle Predisposing factors Shallow anterior chamber, which may be associated with farsightedness or a small eye (short axial length) Enlargement of the crystalline lens with age Inheritance, such as among Inuits and Asians Closure of the angle is precipitated by pupillary dilation and can occur From sitting in a darkened theater During times of stress Following non-ocular administration of anticholinergic or sympathomimetic agents, for example Nebulized bronchodilators Atropine for preoperative medication Antidepressants Bowel or bladder antispasmodics Nasal decongestants Tocolytics From pharmacologic mydriasis (rarely) +++ Secondary acute angle-closure glaucoma ++ Does not require a preexisting narrow angle May occur in anterior uveitis, with dislocation of the lens, with hemodialysis, or due to various drugs Symptoms are the same as in primary acute angle-closure glaucoma, but differentiation is important because of different management + Clinical Findings Download Section PDF Listen +++ +++ Symptoms and Signs ++ Patients usually seek treatment immediately because of extreme pain and blurred vision, though there are subacute cases May present as recurrent headache in subacute cases Typically, the blurred vision is associated with halos around lights Nausea and abdominal pain may occur The eye is red, the cornea cloudy, and the pupil moderately dilated and nonreactive to light +++ Differential Diagnosis ++ Conjunctivitis Acute uveitis Corneal disorders + Diagnosis Download Section PDF Listen +++ ++ Intraocular pressure is usually over 50 mm Hg, producing a hard eye on palpation + Treatment Download Section PDF Listen +++ ++ Reduction of intraocular pressure is initial treatment, regardless of mechanism Acetazolamide, a single 500-mg intravenous dose followed by 250 mg orally four times a day, together with topical medications that lower intraocular pressure is usually sufficient Osmotic diuretics, such as oral glycerin and intravenous urea or mannitol May be necessary if there is no response to acetazolamide Dosage of all three: 1–2 g/kg Definitive treatment depends on the mechanism +++ Primary acute angle-closure glaucoma ++ Topical 4% pilocarpine Used when intraocular pressure starts to fall to reverse underlying angle closure Dosage: 1 drop every 15 minutes for 1 hour and then four times a day Laser peripheral iridotomy or surgical peripheral iridectomy Definitive treatment All patients 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 Cataract extraction is a possible alternative +++ Secondary acute angle-closure glaucoma ++ Additional treatment is determined by the cause + Outcome Download Section PDF Listen +++ +++ Prognosis ++ If left untreated, severe and permanent visual loss occurs within 2–5 days after onset of symptoms Affected patients need to be monitored for development of chronic glaucoma +++ When to Refer ++ Any patient in whom acute angle-closure glaucoma is suspected must be referred emergently to an ophthalmologist + References Download Section PDF Listen +++ + +Ah-Kee EY et al. A review of drug-induced acute angle closure glaucoma for non-ophthalmologists. Qatar Med J. 2015 May 10;2015(1):6. [PubMed: 26535174] + +Chua PY et al. The incidence of acute angle closure in Scotland: a prospective surveillance study. Br J Ophthalmol. 2017 Aug 9. [Epub ahead of print] [PubMed: 28794074] + +Gillan SN et al. Trends in acute primary angle-closure glaucoma, peripheral iridotomy and cataract surgery in Scotland, 1998–2012. Ophthalmic Epidemiol. 2016;23(1):1–5. [PubMed: 26751514] + +Prum BE Jr et al. Primary Angle Closure Preferred Practice Pattern(®) Guidelines. Ophthalmology. 2016 Jan;123(1):P1–40. [PubMed: 26581557] + +Zhang X et al. Why does acute primary angle closure happen? Potential risk factors for acute primary angle closure. Surv Ophthalmol. 2017 Sep–Oct;62(5):635–47. [PubMed: 28428109]