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Acute Angle-Closure Glaucoma
Aka: Acute Angle-Closure Glaucoma, Narrow Angle Glaucoma, Primary Angle-Closure Glaucoma, PACG
- See Also
- Glaucoma
- Open Angle Glaucoma
- Acute Red Eye
- Eye Pain without Redness
- Acute Vision Loss
- Epidemiology
- Relatively rare compared with Open Angle Glaucoma
- Risk factors
- Increasing age
- Hyperopia (Far-sightedness)
- Family History of Glaucoma
- Angle closure Glaucoma in contralateral eye
- Pupillary dilation
- Anatomic variant with shallow anterior chamber
- Female gender (2.4 Relative Risk)
- Asian or Inuit race
- Causes: Precipitating Factors
- Dim lighting (results in Mydriasis of the pupil)
- Eye Dilating Drops (Mydriatics)
- Ophthalmic Anticholinergic Agents
- Systemic medications (cause ciliary body edema)
- Antidepressants
- Sulfa-based medications
- Topiramate
- Pathophysiology
- Drainage obstruction of aqueous from anterior chamber
- Physical blockage of outflow tract by iris
- Narrowing of anterior chamber angle
- Increased aqueous production
- Symptoms
- Acute (Usual presentation)
- Decreased Visual Acuity, Blurred Vision
- Severe Vision Loss in hours to days
- Visual halos or rainbows may occur around streetlights from Corneal edema
- Photophobia
- Headache
- Extreme unilateral Eye Pain
- Nausea and Vomiting
- Abdominal discomfort
- Sub-acute
- Mild Eye Pain
- Visual changes
- Colored halos or rainbows seen around streetlights (results from Corneal edema)
- Visual changes less pronounced with Miosis (well-lit room, on awakening)
- Tunnel vision
- Headache
- Signs
- Shallow Anterior Chamber Depth
- Decreased Visual Acuity
- Pupil mildly dilated (4-6 mm) and sluggishly reactive
- Globe feels firm or rock-hard on palpation through upper Eyelid
- Increased Intraocular Pressure >30 - 60 mmHg
- Eye Redness
- Conjunctival edema (Chemosis)
- Corneal edema
- Cornea cloudy, "steamy", hazy
- Ciliary Flush
- Fundoscopy
- Avoid dilated Eye Exam (risk of worsening Narrow Angle Glaucoma)
- See Open Angle Glaucoma
- See Fundoscopy
- Optic disc cupping
- Gonioscopy (performed by ophthalmologist)
- Differential Diagnosis
- See Acute Red Eye
- See Eye Pain without Redness
- See Acute Vision Loss
- Open Angle Glaucoma
- Narrow Angle Glaucoma often misdiagnosed as:
- Migraine Headache
- Gastroenteritis
- Management
- Immediate ophthalmology referral
- Goal is ophthalmologist contact within 1 hour of patient arrival
- Analgesics and Antiemetics
- Treat both eyes (typically progresses to involve both eyes)
- Temporizing measures
- Give Acetazolamide 500 mg orally or IV AND
- Administer all 3 ophthalmic medications (repeated every 5 minutes for 3 doses)
- Timolol maleate 0.5% (Timoptic) AND
- Apraclonidine 1% (Iopidine) given 1 minute after Timolol AND
- Pilocarpine 2% (Isoptocarpine) given 1 minute after Apraclonidine
- Pilocarpine is only effective after lowering eye pressure with Timolol
- Timolol decreases the ischemic paralysis of the iris
- Monitor Intraocular Pressure hourly until patient is seen by ophthalmology
- Surgery (definitive treatment)
- Laser iridotomy
- Laser iridectomy
- Laser peripheral iris genioplasty
- References
- Gupta (2016) Am Fam Physician 93(8):668-74 [PubMed]
- Sharma (2000) Can Fam Physician 46:303-12 [PubMed]
- Pokhrel (2007) Am Fam Physician 76:829-36 [PubMed]