Angle-closure glaucoma
Intro
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).
Presentation
- Halos around lights
- Blurred vision
- Ocular pain
- Eye redness
- Headache
- Nausea/ Vomiting
History
- 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)
Examination
- 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
Tonometry
- raised IOP, usually > 60 mmHg
Gonioscopy
- Closure of the iridocorneal angle
- Trabecular meshwork NOT visible
Perimetry
- Visual field (VF) defects
Management
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
Complications
- Subsequent attacks in fellow eye
- Loss of vision
- Permanent decrease in VA
- Retinal vein occlusion
page revision: 9, last edited: 06 Apr 2017 21:46