Acute Angle-Closure Glaucoma Clinical Presentation

  • Author: Andrew Aherne, MD; Chief Editor: Steven C Dronen, MD, FAAEM   more...
 
Updated: Nov 10, 2010
 

History

Classically, patients are elderly, suffer from hyperopia, and have no history of glaucoma.

  • Most commonly, they present with periorbital pain and visual deficits.[6] The pain is boring in nature and associated with an ipsilateral headache.
  • Patients note blurry vision and describe the phenomenon of "seeing halos around objects."
  • Careful investigation may elucidate a precipitating factor, such as dim light or medications (eg, anticholinergics, sympathomimetics).
  • In a large percentage of patients, extraocular symptoms and systemic manifestations are the chief complaint.
    • Patients present with headache and may receive medications for migraines or an evaluation for a subarachnoid hemorrhage.
    • Several case reports discuss patients presenting with vomiting and abdominal pain that were misdiagnosed with gastroenteritis.[7]
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Physical

  • The emergency department evaluation of the eye includes visual acuity, the external eye, visual fields, a funduscopic examination, pupils, ocular motility, and IOP. All of which tend to be affected in AACG.
  • Slit lamp evaluation may reveal corneal edema, synechiae, irregular pupil shape or function, or segmental iris atrophy.
  • Patients complain of blurred vision, and testing reveals the ability only to detect hand movements. They are unable to identify numbers and letters on distance charts or near cards.
  • Cornea and scleral injection and ciliary flush are present. The obviously edematous and cloudy cornea obscures the funduscopic examination.
  • Increased IOP (normal limit, 10-20 mm Hg) and ischemia result in pain on eye movement, a mid-dilated nonreactive pupil, and a firm globe. Clinicians must take a comprehensive history and perform a thorough physical examination to ensure that this time-sensitive diagnosis is not missed.
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Causes

  • Shallower anterior chambers; anteriorly situated lens; shorter axial eye length; thick iris; overdeveloped iris dilator muscles; and a narrow angle lead to a higher propensity for development of AACG.
  • Precipitating factors include drugs (ie, sympathomimetics, anticholinergics, antidepressants [SSRIs], sulfonamides, cocaine, botulinum toxin)[8, 9, 10] , dim light, and rapid correction of hyperglycemia.
  • Case reports have identified AACG associated with carotid-cavernous sinus fistula, trauma, prone surgical positioning, and giant cell arteritis.[11, 12, 13]
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Contributor Information and Disclosures
Author

Andrew Aherne, MD  Resident Physician, Department of Emergency Medicine, Kings County Hospital Center, University Hospital of Brooklyn

Disclosure: Nothing to disclose.

Coauthor(s)

Richard H Sinert, DO  Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Michelle Ervin, MD  Chair, Department of Emergency Medicine, Howard University Hospital

Michelle Ervin, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Douglas Lavenburg, MD  Clinical Professor, Department of Emergency Medicine, Christiana Care Health Systems

Douglas Lavenburg, MD is a member of the following medical societies: American Society of Cataract and Refractive Surgery

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM  Chair, Department of Emergency Medicine, LeConte Medical Center

Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Ayim K Darkeh, MD, and Mark A Silverberg, MD, to the development and writing of this article.

References

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