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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

    • Occurs in eyes with narrow anterior chamber angles, for which precipitating factors are

      • Shallow anterior chamber, which may be associated with farsightedness or a small eye (short axial length)

      • 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

      • Medications with anticholinergic or sympathomimetic activity

      • Pharmacologic mydriasis for ophthalmologic examination (rarely)

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

  • Secondary acute angle-closure glaucoma

    • Does not require a preexisting narrow angle

      • May occur in uveitis, with hemodialysis, or with medications with anticholinergic or sympathomimetic activity (rare)

    • Important to differentiate from primary acute angle-closure glaucoma because of differences in management

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 > 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

    • Surgical peripheral iridectomy

    • Cataract extraction, which is becoming first-line treatment for primary acute angle-closure glaucoma

  • 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

Outcome

Prognosis

  • Untreated acute angle-closure glaucoma results in severe and permanent visual loss within 2–5 days after onset of symptoms

  • Affected patients need to be monitored for development of chronic glaucoma

When to Refer

  • Any patient with suspected acute angle-closure glaucoma must be referred emergently to an ophthalmologist

References

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Prum  BE Jr  et al. Primary Angle ...

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