Acute Angle-Closure Glaucoma

Aka: Acute Angle-Closure Glaucoma, Narrow Angle Glaucoma, Primary Angle-Closure Glaucoma, PACG

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II. Epidemiology

  1. Accounts for 10% of Glaucoma cases
    1. Relatively uncommon compared with Open Angle Glaucoma
    2. Worldwide, 75% of acute angle Glaucoma occurs in Asia

III. Pathophysiology

  1. Increased aqueous production
  2. Drainage obstruction of aqueous from anterior chamber (normally drains at margin between Cornea and iris)
    1. Physical blockage of outflow tract by iris (trabecular network)
    2. Narrowing of anterior chamber angle

IV. Risk factors

  1. See Medications Associated With Narrow Angle Glaucoma
  2. Increasing age
  3. Hyperopia (Farsightedness)
  4. Family History of Glaucoma
  5. Angle closure Glaucoma in contralateral eye
  6. Advanced Cataract
  7. Pupillary dilation
  8. Anatomic variant with shallow anterior chamber
  9. Female gender (2.4 Relative Risk)
  10. Asian descent (esp. southeast asia and Chinese)
  11. Inuit race (Alaskan Native)
  12. Older patient with Cataracts

V. Causes: Precipitating Factors (Mydriasis with angle obstruction)

  1. Dim lighting or dark room (results in Mydriasis of the pupil)
  2. Eye Dilating Drops (Mydriatics)
  3. Ophthalmic Anticholinergic Agents
  4. Systemic medications (cause ciliary body edema)
    1. See Medications Associated With Narrow Angle Glaucoma

VI. Symptoms

  1. Acute (Usual presentation)
    1. Extreme unilateral Eye Pain
      1. Lack of Eye Pain does not exclude Narrow Angle Glaucoma
    2. Visual changes
      1. Decreased Visual Acuity, Blurred Vision (severe Vision Loss in hours to days)
      2. Colored visual halos or rainbows may occur around streetlights from Corneal edema
    3. Photophobia
    4. Frontal Headache
    5. Nausea and Vomiting
    6. Abdominal discomfort
  2. Sub-acute
    1. Mild Eye Pain
    2. Visual changes
      1. Colored halos or rainbows seen around streetlights (results from Corneal edema)
      2. Visual changes less pronounced with Miosis (well-lit room, on awakening)
      3. Tunnel Vision
    3. Headache

VII. Signs

  1. Shallow Anterior Chamber Depth
  2. Decreased Visual Acuity
  3. Pupil mildly dilated (4-6 mm) and sluggishly reactive
  4. Globe feels firm or rock-hard on palpation through upper Eyelid
  5. Increased Intraocular Pressure >30 to 60 mmHg
    1. See Intraocular Pressure
    2. Pressure in acute Narrow Angle Glaucoma is typically >40 mmHg
    3. Discuss suspected Glaucoma with ophthalmology
  6. Eye Redness (Acute Red Eye)
    1. Conjunctival injection
  7. Conjunctival edema (Chemosis)
  8. Corneal edema
    1. Cornea cloudy, "steamy", hazy
  9. Ciliary Flush
  10. Fundoscopy
    1. Avoid dilated Eye Exam (risk of worsening Narrow Angle Glaucoma)
    2. See Open Angle Glaucoma
    3. See Fundoscopy
    4. Optic Disc cupping
  11. Gonioscopy (Van Herrick Test)
    1. Performed by ophthalmologist
    2. Van Herrick Test
      1. https://www.aao.org/basic-skills/van-herick-technique
      2. Temporal (lateral) edge of Cornea-iris margin is viewed at 60 degree angle with Slit Lamp
      3. Using narrow beam of light from Slit Lamp, width of Cornea is compared with width of anterior chamber

VIII. Differential Diagnosis

  1. See Acute Red Eye
  2. See Eye Pain without Redness
  3. See Acute Vision Loss
  4. Open Angle Glaucoma
  5. Narrow Angle Glaucoma often misdiagnosed as:
    1. Migraine Headache
    2. Gastroenteritis

IX. Management

  1. Immediate ophthalmology referral
    1. Goal is ophthalmologist contact within 1 hour of patient arrival ("time is Optic Nerve")
    2. Abrupt onset with blockage of aqueous drainage (e.g. Mydriatic use) is an ophthalmologic emergency
      1. Permanent Vision Loss may occur within hours
  2. Analgesics and Antiemetics
  3. Treat both eyes (typically progresses to involve both eyes)
  4. Temporizing measures
    1. Give Carbonic Anhydrase Inhibitor
      1. Dorzolamide eye drops (in combination with drops below)
      2. Acetazolamide 500 mg orally or IV
        1. Indicated if refractory to topical agents or may use in place of Dorzolamide to start
    2. Also administer all 3 ophthalmic medications (repeated every 5 minutes for 3 doses)
      1. Timolol maleate 0.5% (Timoptic) AND
      2. Apraclonidine 1% (Iopidine) or Brimonidine (Alphagan) given 1 minute after Timolol AND
        1. May also use Combigan (combined Timolol and Brimonidine) after initial Timolol dose
      3. Pilocarpine 2% (Isoptocarpine) given 1 minute after Apraclonidine
        1. Pilocarpine is only effective after lowering eye pressure with Timolol
        2. Timolol decreases the ischemic paralysis of the iris
        3. Alternatively, Latanoprost may be used instead
    3. Recheck Intraocular Pressure 30 minutes after above medications given
      1. If no response to above medications, give Acetazolamide IV if not already given
    4. Monitor Intraocular Pressure hourly until patient is seen by ophthalmology
  5. Surgery (definitive treatment)
    1. Laser peripheral iridotomy
      1. Allows iris to fall back into normal position (and anterior chamber drainage to resume)
    2. Laser iridectomy
    3. Laser peripheral Iridoplasty (iris gonioplasty)
    4. Lens extraction
    5. Anterior Chamber Paracentesis

X. References

  1. Khazaeni (2022) Acute Closed Angle Glaucoma, StatPearls, Treasure Island, FL
    1. https://www.ncbi.nlm.nih.gov/books/NBK430857/
  2. St. Peter and Werner in Swadron (2022) EM:Rap 22(4): 4-6
  3. Gupta (2016) Am Fam Physician 93(8):668-74 [PubMed]
  4. Michels (2023) Am Fam Physician 107(3): 253-62 [PubMed]
  5. Sharma (2000) Can Fam Physician 46:303-12 [PubMed]
  6. Pokhrel (2007) Am Fam Physician 76:829-36 [PubMed]

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Related Studies

Ontology: Angle Closure Glaucoma (C0017605)

Definition (MSH) A form of glaucoma in which the intraocular pressure increases because the angle of the anterior chamber is blocked and the aqueous humor cannot drain from the anterior chamber.
Concepts Disease or Syndrome (T047)
MSH D015812
SnomedCT 392291006, 270882001, 193544008, 33647009
English Angle Closure Glaucomas, Angle-Closure Glaucoma, Angle-Closure Glaucomas, Closed-Angle Glaucoma, Closed-Angle Glaucomas, Glaucoma, Angle Closure, Glaucoma, Angle-Closure, Glaucoma, Closed Angle, Glaucoma, Closed-Angle, Glaucoma, Narrow-Angle, Glaucoma, Uncompensated, Glaucoma, Uncompensative, Glaucomas, Angle Closure, Glaucomas, Angle-Closure, Glaucomas, Closed-Angle, Glaucomas, Narrow-Angle, Glaucomas, Uncompensated, Glaucomas, Uncompensative, Narrow-Angle Glaucoma, Narrow-Angle Glaucomas, Uncompensated Glaucoma, Uncompensated Glaucomas, Uncompensative Glaucoma, Uncompensative Glaucomas, Glaucoma, Narrow Angle, ACG - Angle closure glaucoma, Narrow angle glaucoma, Narrow-angle glaucoma, angle-closure glaucoma (diagnosis), angle-closure glaucoma, Angle glaucoma closed, Glaucoma closed angle, Angle closure glaucoma, Glaucoma, Angle-Closure [Disease/Finding], angle closure glaucoma, glaucoma angle-closure, narrow glaucoma angle, narrow angle glaucoma, closed angle glaucoma, glaucoma narrow angle, close angle glaucoma, angles glaucoma narrow, closed-angle glaucoma, glaucoma closed angle, narrow-angle glaucoma, ACG - Angle-closure glaucoma, Closed-angle glaucoma, Closed angle glaucoma, Narrow cleft glaucoma, Angle-closure glaucoma (disorder), Angle-closure glaucoma, glaucoma; angle-closure, glaucoma; narrow angle, glaucoma; obstructive, narrow angle; glaucoma, obstructive; glaucoma, angle-closure; glaucoma, Angle Closure Glaucoma
German Glaukom Winkelblock, Winkelblockglaukom, Engwinkelglaukom, Glaukom, Winkelblock-
Swedish Trångvinkelglaukom
Japanese ﾍｲｿｸｸﾞｳｶｸﾘｮｸﾅｲｼｮｳ, 閉塞隅角緑内障, 緑内障-閉塞隅角
Czech glaukom s uzavřeným úhlem, Glaukom uzavřeného úhlu, Glaukom s uzavřeným úhlem
Finnish Ahdaskulmaglaukooma
Russian ZAKRYTOUGOL'NAIA GLAUKOMA, GLAUKOMA ZAKRYTOUGOL'NAIA, ГЛАУКОМА ЗАКРЫТОУГОЛЬНАЯ, ЗАКРЫТОУГОЛЬНАЯ ГЛАУКОМА
Italian Glaucoma ad angolo stretto, Glaucoma ad angolo chiuso, Glaucoma non compensato
Polish Jaskra zamkniętego kąta
Hungarian Zártzugú glaucoma, Csarnokzúg glaucoma, zárt
Norwegian Glaukom, ukompensert, Trangvinkelglaukom
Dutch gesloten kamerhoek; glaucoom, glaucoom; gesloten kamerhoek, glaucoom; nauwe kamerhoek, glaucoom; obstructief, nauwe kamerhoek; glaucoom, obstructief; glaucoom, kamerhoekblok-glaucoom, Geslotenkamerhoekglaucoom, Glaucoom, geslotenkamerhoek-
Spanish glaucoma de ángulo cerrado (trastorno), glaucoma de ángulo cerrado, glaucoma de ángulo estrecho, Glaucoma de ángulo cerrado, Glaucoma de Ángulo Cerrado
Portuguese Glaucoma de ângulo fechado, Glaucoma de Ângulo Fechado
French Glaucome à angle fermé, Glaucome par fermeture de l'angle irido-cornéen, Glaucome par fermeture de l'angle iridocornéen, Glaucome par fermeture de l'angle, Glaucome à angle étroit
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Primary angle-closure glaucoma (C0017606)

Concepts Disease or Syndrome (T047)
ICD9 365.20, 365.2
ICD10 H40.2 , H40.20
SnomedCT 193547001, 193545009, 193544008, 42456004, 155123006, 270882001, 392288006
English ACG - Angle-closure glaucoma, Primary angle-closure glaucoma NOS, Primary angle-closure glaucoma, unspecified, Primary close-ang.glaucom.unsp, Primary close-ang.glaucoma NOS, primary angle-closure glaucoma (diagnosis), primary angle-closure glaucoma, Primary angle-closure glaucoma, Prim angl-clos glauc NOS, Unspecified primary angle-closure glaucoma, Primary angle-closure glaucoma NOS (disorder), Unspecified primary angle-closure glaucoma (disorder), Primary angle-closure glaucoma (disorder), Primary angle-closure glaucoma, NOS, Primary Angle Closure Glaucoma
Dutch primair kamerhoekblok-glaucoom, primair kamerhoekblok-glaucoom, niet-gespecificeerd, Primair gesloten-kamerhoekglaucoom
French Glaucome primitif à angle fermé, Glaucome primitif à angle fermé, non précisé
German primaeres Winkelblockglaukom, unspezifisch, primaeres Winkelblockglaukom, Primaeres Engwinkelglaukom
Italian Glaucoma primario ad angolo chiuso, non specificato, Glaucoma primario ad angolo chiuso
Portuguese Glaucoma de ângulo fechado primário, Glaucoma de ângulo fechado primário NE
Spanish Glaucoma primario de ángulo cerrado, Glaucoma de ángulo cerrado primario no especificado, glaucoma primario de cierre de ángulo, glaucoma de ángulo agudo, glaucoma primario de ángulo cerrado, SAI, glaucoma primario de ángulo estrecho, glaucoma primario de ángulo cerrado, no especificado, glaucoma primario de cierre de ángulo (concepto no activo), glaucoma primario de ángulo cerrado, no especificado (trastorno), glaucoma primario de ángulo estrecho (trastorno), glaucoma primario de ángulo cerrado, SAI (trastorno), glaucoma primario de ángulo agudo (trastorno), glaucoma primario de ángulo agudo
Japanese 原発閉塞隅角緑内障, 原発性閉塞隅角緑内障、詳細不明, ｹﾞﾝﾊﾟﾂﾍｲｿｸｸﾞｳｶｸﾘｮｸﾅｲｼｮｳ, ｹﾞﾝﾊﾟﾂｾｲﾍｲｿｸｸﾞｳｶｸﾘｮｸﾅｲｼｮｳｼｮｳｻｲﾌﾒｲ
Czech Blíže neurčený primární glaukom s uzavřeným úhlem, Primární glaukom s uzavřeným úhlem
Korean 원발성 폐쇄우각 녹내장
Hungarian Primaer zártzugú glaucoma, nem meghatározott, Primaer zártzugú glaucoma
Derived from the NIH UMLS (Unified Medical Language System)

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