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For further information, see CMDT Part 7-10: Acute Angle-Closure Glaucoma

Key Features

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

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

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

Treatment

  • 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 ...

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