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acute angle-closure glaucoma

An uncommon form of glaucoma considered an ocular emergency. Etiology: 1) iridocorneal angle crowding 2) pupillary block 3) neovascularization 4) inflammation of a membrane closing the iridocorneal angle 5) mechanical closure of the iridocorneal angle secondary to anterior displacement of the lens-iris diaphragm - cataracts [6] 6) precipitating factors a) labor of pregnancy (rare) b) sneezing c) ocular laser therapy d) ocular surgery e) ocular injury f) pharmacologic agents [8] 1] mydriatics 2] sympathomimetics 3] antihistamines - chlorpheniramine with highest risk 4] neurologic agents & psychotropic agents - sumatriptan, topiramate, & duloxetine with highest risk [8] 5] acetylcysteine with high risk 6] others: (lower risk) - amitriptyline, escitalopram, nortriptyline - alprazolam, diazepam, buspirone - aminophylline, pseudoephedrine - lactulose, metoclopramide, dimenhydrinate - solifenacin - naproxen, ibuprofen, orphenadrine - levofloxacin, ofloxacin, clarithromycin - prednisolone, methylprednisolone - ammonium chloride 7] table of 61 drugs [8] 7) risk factors - hyperopia: smaller eyes with narrower angles [6] Epidemiology: 1) more common with hyperopia (far-sightedness) 2) more common in women 3) more common in Alaskan natives Pathology: - blockage of the anterior chamber angle structure by the peripheral iris, thus preventing aqueous humor outflow - the iris may come into contact with the lens & block outflow of aqueous humor [9] - elevated intraocular pressure - blurry vision & hazy cornea - damage to the optic nerve Clinical manifestations: 1) acute onset 2) severe eye pain 3) blurred vision (may be triggered by low light) 4) injected conjunctiva (erythema) 5) complaints of colored halos around lights 6) nausea/vomiting 7) frontal headache 8) red eye, conjunctival hyperemia 9) semidilated pupil(s), minimally reactive to light or unreactive to light [5] 10) increased intraocular pressure, 55 mm Hg (case report) [5] 11) corneal edema, hazy cornea 12) shallow anterior chamber 13) closed iridocorneal angle in the involved eye 14) blindness within a few hours to days if not diagnosed & treated immediately 15) eye may feel firm & tender to palpation 16) no erythema or edema of eyelids or surrounding eye structures * image [5] Special laboratory: - ophthalmoscopy a) may be normal b) optic disk cupping if chronic c) hazy cornea without fluorescein staining Differential diagnosis: - orbital cellulitis - erythema &/or edema of eyelids & surrounding structures - no frontal headache - no halos around lights - uveitis: red eye, photophobia - scleritis: - painful red eye, photophobia, edema of sclera - dilation of episcleral blood vessels - corneal abrasion: red eye,clear cornea, eye foreign body sensation - corneal ulcer: eye foreign body sensation, red eye, corneal opacity - giant cell arteritis: no eye pain - bacterial keratitis: - contact lenses users - eye pain, redness, foreign body sensation - no halos around lights, nausea/vomiting, or periorbital headache Management: 1) rapidly relieve increased intraocular pressure 2) referral to ophthalmology [2] - pilocarpine 2%, 2 drops in affected eye [3] - send to ophthalmology 3) laser therapy - peripheral iridectomy 4) surgery: iridotomy within hour of symptom onset [2] 5) pharmacologic agents a) miotics b) mannitol 6) 50% incidence of acute angle-closure in the other eye within 5 years, thus long-term treatment is indicated

Related

glaucomatocyclitic crisis (Posner-Schlossman Syndrome) increased intraocular pressure (IOP)

Specific

plateau iris syndrome

General

secondary glaucoma

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 66-67
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 18. 19 American College of Physicians, Philadelphia 1998, 2009, 2012, 2018, 2022. - Magauran B. Conditions requiring emergency ophthalmologic consultation. Emerg Med Clin North Am. 2008 Feb;26(1):233-8 PMID: 18249265
  3. Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004; 7th edition 2010
  4. NEJM Knowledge+ Question of the Week. June 20, 2017 https://knowledgeplus.nejm.org/question-of-week/1501/
  5. Pohl H, Tarnutzer AA. Acute Angle-Closure Glaucoma. N Engl J Med 2018; 378:e14 PMID: 29514027 http://www.nejm.org/doi/full/10.1056/NEJMicm1712742
  6. Hobbs BN Seeing Red: Five Eye Diagnoses Not to Miss Medscape - Apr 23, 2018. https://www.medscape.com/viewarticle/895295
  7. Wu AM, Stein JD, Shah M Potentially Missed Opportunities in Prevention of Acute Angle-Closure Crisis. JAMA Ophthalmol. 2022;140(6):598-603. PMID: 35554487 PMCID: PMC9100468 Free PMC article https://jamanetwork.com/journals/jamaophthalmology/fullarticle/2792083 - Day AC, Gazzard G Missed Opportunities in Preventing Acute Angle Closure - Needlessly Blind? JAMA Ophthalmol. 2022;140(6):604-605 PMID: 35551583 https://jamanetwork.com/journals/jamaophthalmology/fullarticle/2792085
  8. Na KI, Park SP. Association of Drugs With Acute Angle Closure JAMA Ophthalmol. 2022;140(11):1055-1063. PMID: 36136326 PMCID: PMC9501771 (available on 2023-09-22) https://jamanetwork.com/journals/jamaophthalmology/fullarticle/2796505
  9. NEJM Knowledge+ Ophthalmology