Acute Angle-Closure Glaucoma in Emergency Medicine Clinical Presentation

Updated: Nov 19, 2018
  • Author: Joseph Freedman, MD; Chief Editor: Steven C Dronen, MD, FAAEM  more...
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Presentation

History

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]

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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 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.

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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], 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]

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