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Acute Angle-Closure Glaucoma Clinical Presentation

  • Author: Joseph Freedman, MD; Chief Editor: Steven C Dronen, MD, FAAEM  more...
Updated: Aug 22, 2016


Classically, patients are elderly, suffer from hyperopia, and have no history of glaucoma. Most commonly, they present with periorbital pain and visual deficits.[8] 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.[9]



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 these 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 decreased visual acuity in the affected eye, often the ability to detect hand movements only. Commonly, 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.



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], anticonvulsants, sulfonamides, cocaine, botulinum toxin),[10, 11, 12, 13, 14] 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.[14, 15, 16]

Contributor Information and Disclosures

Joseph Freedman, MD Resident Physician, Department of Emergency Medicine, State University of New York Downstate, King's County Hospital Center

Joseph Freedman, MD is a member of the following medical societies: Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.


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

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

Disclosure: Nothing to disclose.

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

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.

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, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.


Ayim K Darkeh, MD Assistant Professor, Department of Emergency Medicine, State University of New York Downstate Medical Center

Ayim K Darkeh is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents Association, National Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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.

Mark A Silverberg, MD, MMB, FACEP Assistant Professor, Associate Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate Medical Center

Mark A Silverberg, MD, MMB, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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