Acute Angle-Closure Glaucoma

1. See Also
   1. Glaucoma
   2. Open Angle Glaucoma
2. Epidemiology
   1. Relatively rare compared with Open Angle Glaucoma
3. Risk factors
   1. Increasing age
   2. Hyperopia (Far-sightedness)
   3. Family History of Glaucoma
   4. Angle closure Glaucoma in contralateral eye
   5. Pupillary dilation
   6. Anatomic variant with shallow anterior chamber
4. Causes: Precipitating Factors
   1. Dim lighting (results in Mydriasis of the pupil)
   2. Eye Dilating Drops (Mydriatics)
   3. Ophthalmic anticholinergic agents
   4. Systemic medications (cause ciliary body edema)
      1. Antidepressants
      2. Sulfa-based medications
      3. Topiramate
5. Pathophysiology
   1. Drainage obstruction of aqueous from anterior chamber
      1. Physical blockage of outflow tract by iris
      2. Narrowing of anterior chamber angle
   2. Increased aqueous production
6. Symptoms
   1. Acute (Usual presentation)
      1. Decreased Visual Acuity or blurred vision
         1. Severe Vision Loss in hours to days
      2. Photophobia
      3. Headache
      4. Extreme Eye Pain
      5. Nausea and Vomiting
      6. Abdominal discomfort
   2. Sub-acute
      1. Mild Eye Pain
      2. Visual changes
         1. Colored halos seen around streetlights
            1. Results from Corneal edema
         2. Tunnel vision
      3. Headache
7. Signs
   1. Shallow Anterior Chamber Depth
   2. Decreased Visual Acuity
   3. Pupil mildly dilated and sluggishly reactive
   4. Globe feels firm or rock-hard on palpation through lid
   5. Increased Intraocular Pressure = 25 - 50 mmHg
   6. Eye redness
   7. Conjunctival edema (Chemosis)
   8. Corneal edema
      1. Cornea cloudy, "steamy", hazy
   9. Ciliary Flush
   10. Fundoscopy
       1. Optic disc cupping
8. Differential Diagnosis
   1. Open Angle Glaucoma
   2. Narrow Angle Glaucoma often misdiagnosed as:
      1. Migraine Headache
      2. Gastroenteritis
9. Management
   1. Immediate ophthalmology referral
   2. Temporizing measures
      1. Give Acetazolamide 500 mg PO AND
      2. Administer all 3 ophthalmic medications (repeated every 5 minutes for 3 doses)
         1. Timolol maleate 0.5% (Timoptic) AND
         2. Apraclonidine 1% (Iopidine) given 1 minute after Timolol AND
         3. Pilocarpine 2% (Isoptocarpine) given 1 minute after Apraclonidine
      3. Monitor Intraocular Pressure hourly until patient is seen by ophthalmology
   3. Surgery (definitive treatment)
      1. Laser iridotomy
      2. Iridectomy
10. References
    1. Sharma (2000) Can Fam Physician 46:303-12
    2. Pokhrel (2007) Am Fam Physician 76:829-36