Acute angle-closure glaucoma

Background

Pathophysiology

• Obstructed aqueous outflow tract ==> aqueous humor builds ==> increased intraocular pressure (IOP) ==> optic nerve damage ==> vision loss
• Increased posterior chamber pressure causes iris to bulge forward (iris bombé) ==> further obstruction of outflow tract ==> further increase IOP
• Acute attack is usually precipitated by pupillary dilation

Definition: 3 signs + 2 symptoms

• At least 3 of these signs
  • IOP >21 mm Hg
  • Conjunctival injection
  • Corneal epithelial edema
  • Mid-dilated nonreactive pupil
  • Shallow anterior chamber with occlusion
• At least 2 of these symptoms
  • Ocular pain
  • Nausea/vomiting
  • History of intermittent blurring of vision with halos

Clinical Features

• Abrupt onset of severe eye pain
• Blurred vision
• Frontal or supraorbital headache
• Nausea / vomiting / abdominal pain

Diagnosis

1. Fixed, midposition pupil
2. Hazy cornea
3. Conjunctival injection (most prominent at limbus)
4. Rock-hard globe
   1. IOP >20

Treatment

1. Emergent ophtho consult
2. Block aqueous humor production
   1. Timolol 0.5%, one drop AND
   2. Apraclonidine 1%, one drop AND
   3. Acetazolamide 500mg IV or PO
3. Reduce volume of aqueous humor
   1. Mannitol 1–2gm/kg IV
   2. Give if no contraindications
4. Facilitate outflow of aqueous humor
   1. Only effective once IOP <40
   2. Pilocarpine 1%–2%, one drop q15min x2 doses; then QID
5. Recheck IOP hourly

See Also

• Eye Algorithm (Main)

Source

Tintinalli