Angle-closure glaucoma


Acute angle-closure glaucoma is an ophthalmologic emergency, caused by the pupillary block mechanism: iris being pushed forward from behind, closing the iridocorneal drainage angle and thus leading to an increase in intraocular pressure (IOP).


  • Halos around lights
  • Blurred vision
  • Ocular pain
  • Eye redness
  • Headache
  • Nausea/ Vomiting


  • Risk Factors (female, hypermetropia, previous occurrence, shallow anterior chamber, Asian ethnicity)
  • Was there an identifiable trigger? (topical pupil dilators, antimuscarinic medication e.g. TCAs, watching TV in a dark room)


  • Reduced visual acuity (VA)
  • Eye appears red with vascular congestion
  • Fixed, dilated pupil

Special investigations

Slit-lamp examination

  • Shallow anterior chamber
  • Corneal oedema
  • Fundoscopy: large optic cup, narrowing of neuroretinal rim


  • raised IOP, usually > 60 mmHg


  • Closure of the iridocorneal angle
  • Trabecular meshwork NOT visible


  • Visual field (VF) defects


Immediate management

  • Topical carbonic anhydrase inhibitors e.g dorzolamide (2%) 1 drop into the affected eye
  • AND/OR Topical beta-blockers e.g. timolol (0.25/ 0.5%) 1 drop into the affected eye
  • AND/OR Topical alpha-2 agonist: brimonidine (0.1-0.2%) 1 drop into the affected eye
  • Topical constricting agents e.g. pilocarpine (1-2%) 1 drop into the affected eye, frequency dependent on response

Failure to resolve/ exceedingly high pressure

  • Hyperosmotic agents e.g. IV mannitol (1.5-2 g/kg/dose) over 30 minutes
  • Laser peripheral iridotomy
  • Anterior chamber paracentesis

Follow up

  • Eye assessment for glaucomatous changes, presence of peripheral anterior synechiae (PAS), cataract, VF changes
  • 6-12 monthly periodic follow-up to monitor changes in VF and IOP


  • Subsequent attacks in fellow eye
  • Loss of vision
  • Permanent decrease in VA
  • Retinal vein occlusion
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