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Angle Closure Glaucoma

Angle closure glaucoma is a disorder of progressive optic nerve damage characterized by an increased intraocular pressure. Obstruction of aqueous humor flow in the anterior chamber causes sudden vision impairment and headaches. A rapid diagnosis is necessary, as blindness can occur without adequate treatment.


Presentation

The clinical presentation of angle closure glaucoma stems from sudden increases in intraocular pressure (IOP), with possible triggers being dim lighting or use of drugs that induce pupillary dilation (eg. anticholinergics), ciliary body swelling (eg. topiramate) [1]. Moreover, anterior placement of the lens (most commonly caused by the gradual development of cataract) [2], myopia, hyperopia, a shallow anterior chamber, but also advanced age and female gender have all been established as potential risk factors for this type of glaucoma [3] [4]. Only about a third of cases develop an acute exacerbation of IOP changes, however, but increased IOP may not cause marked eye-related symptoms in the beginning [5]. Unfortunately, patients frequently report when profound visual deficits have already occurred, especially in chronic forms, thus reducing the chance of total sight repair [4] [5]. Most prominent symptoms of acute angle closure glaucoma are blurred vision, redness of the eye, ocular discomfort, colored halos around lights and frontal headaches accompanied by nausea and vomiting. Gastrointestinal complaints and headaches may mislead the physician by suggesting a gastrointestinal or central nervous system origin of symptoms [1] [3], and it is not uncommon for glaucoma patients to undergo detailed gastrointestinal or CNS workup prior to their diagnosis [2]. In some patients, a prolonged (chronic) clinical course may be observed, distinguished by ocular discomfort and headaches that are alleviated with sleep [1]. In the setting of a delayed diagnosis, irreversible blindness can occur rapidly, which is why early recognition is detrimental in achieving good outcomes [4].

Sepsis
  • A 62-year-old man visited our emergency center with signs of sepsis (fever, leukocytosis, and oliguria). After 4 days of hospitalization, the patient reported blurred vision.[ncbi.nlm.nih.gov]
Weight Loss
  • Physicians prescribing weight loss medications containing Ma-huang must be aware of the potentially sight-threatening adverse effect of bilateral acute angle closure.[ncbi.nlm.nih.gov]
Lower Extremity Pain
  • A 68-year-old Caucasian woman presented with persistent low back and left lower extremity pain. History was remarkable for L5 radicular pain, spinal stenosis, and an L3-L4 laminectomy performed 6 months previously.[ncbi.nlm.nih.gov]
Wheelchair Bound
  • We hope that this case report may help prevent vision loss and optimize quality of life in patients with MLS who may be wheelchair-bound but are typically high functioning with normal intelligence.[ncbi.nlm.nih.gov]
Fishing
  • A 56-year-old woman with a history of primary angle-closure glaucoma presented with acute generalised swelling, and facial angioedema following a fish meal. She complained of nausea, vomiting, headache, pain in both eyes and acute loss of vision.[ncbi.nlm.nih.gov]
Cough
  • She had persistent dry cough while taking medication for 3 months, and had usual posterior neck pain, which was treated with analgesic medication and Asian medicines. Intraocular pressure was 32 and 34 mmHg in her right and left eyes, respectively.[ncbi.nlm.nih.gov]
  • Many other drugs can influence the anterior chamber angle, such as Bronchodilators, Antidepressants, Anticholinergics, General Anaesthetics, Cough Suppressants, Recreational Drugs, Botulinum Toxin, Sympathomimetics and Poisons (like Belladonna).[omicsonline.org]
Dry Cough
  • She had persistent dry cough while taking medication for 3 months, and had usual posterior neck pain, which was treated with analgesic medication and Asian medicines. Intraocular pressure was 32 and 34 mmHg in her right and left eyes, respectively.[ncbi.nlm.nih.gov]
Nausea
  • We present a case of a 63-year-old woman who presented to an ED with bifrontal headache, nausea and vomiting and reduced visual acuity.[ncbi.nlm.nih.gov]
Angioedema
  • A 31-year-old woman presented with decreased visual acuity, nausea, vomiting, fever, and bilateral angioedema-like eyelid swelling.[ncbi.nlm.nih.gov]
Neck Pain
  • She had persistent dry cough while taking medication for 3 months, and had usual posterior neck pain, which was treated with analgesic medication and Asian medicines. Intraocular pressure was 32 and 34 mmHg in her right and left eyes, respectively.[ncbi.nlm.nih.gov]
Joint Stiffness
  • Weill Marchesani syndrome (WMS) is a rare condition characterized by short stature, brachydactyly, joint stiffness, and characteristic eye abnormalities including microspherophakia, ectopia of the lens, severe myopia, and glaucoma.[ncbi.nlm.nih.gov]
Brachydactyly
  • Weill Marchesani syndrome (WMS) is a rare condition characterized by short stature, brachydactyly, joint stiffness, and characteristic eye abnormalities including microspherophakia, ectopia of the lens, severe myopia, and glaucoma.[ncbi.nlm.nih.gov]
Blurred Vision
  • CASE REPORT: A 23 year-old woman developed bilateral severe blurred vision seven days after initiating therapy with topiramate. Her visual acuity was counting fingers in both eyes.[ncbi.nlm.nih.gov]
  • As the pressure rises, the ache worsens, and visual symptoms worsen with blurred vision as the eye cornea clouds over.[clinicalondon.co.uk]
  • Most prominent symptoms of acute angle closure glaucoma are blurred vision, redness of the eye, ocular discomfort, colored halos around lights and frontal headaches accompanied by nausea and vomiting.[symptoma.com]
Eye Pain
  • All patients with inherited retinopathy presenting with a headache or eye pain should undergo gonioscopic examination to exclude angle-closure glaucoma.[ncbi.nlm.nih.gov]
  • A short case presentation of an 82-year-old woman with left eye pain demonstrates the utility of bedside ultrasound in diagnosing acute angle closure glaucoma. Case An 82-year-old woman presented to the ED for evaluation of left eye pain.[mdedge.com]
  • Symptoms of angle-closure glaucoma may include: Hazy or blurred vision The appearance of rainbow-colored circles around bright lights Severe eye and head pain Nausea or vomiting (accompanying severe eye pain) Sudden sight loss In contrast with open-angle[glaucoma.org]
  • Some early symptoms in people at risk for angle-closure glaucoma include blurred vision, halos in their vision, headache, mild eye pain or redness. People who are at risk for developing angle-closure glaucoma should have a laser iridotomy.[sharecare.com]
  • Our case is remarkable because of the clear temporal relationship between development of acute eye pain and the rapid drop in plasma glucose levels.[care.diabetesjournals.org]
Retinal Pigmentation
  • Fundus examination disclosed punctate hypopigmentation of the retinal pigment epithelium mainly at the posterior pole. Optical coherence tomography showed foveal schisis appearing as small retinal cysts.[ncbi.nlm.nih.gov]
Corneal Opacity
  • OCT proved to be very useful in case of corneal opacity that makes angle visualization gonioscopically unclear as in acute angle-closure glaucoma; images can be taken with only minimal degradation [ 105 ].[omicsonline.org]
Retinal Cyst
  • Optical coherence tomography showed foveal schisis appearing as small retinal cysts. The patient did not display any systemic abnormalities.[ncbi.nlm.nih.gov]
Facial Pain
  • When symptoms of acute angle glaucoma do develop, they may include severe eye and facial pain, nausea and vomiting, decreased vision, blurred vision and seeing haloes around light.[medicinenet.com]
Malar Rash
  • During evaluation of the drug-induced angioedema in the internal medicine department, systemic lupus erythematosus was diagnosed, based on malar rash, photosensitivity, proteinuria, and positive anti-Smith and anti-DNA antibodies, followed by initiation[ncbi.nlm.nih.gov]
Oliguria
  • A 62-year-old man visited our emergency center with signs of sepsis (fever, leukocytosis, and oliguria). After 4 days of hospitalization, the patient reported blurred vision.[ncbi.nlm.nih.gov]
Headache
  • In some patients, a prolonged (chronic) clinical course may be observed, distinguished by ocular discomfort and headaches that are alleviated with sleep.[symptoma.com]
  • A case of 72 years male, who developed headache and vomiting after five days of demise of his mother followed by blurring of vision. He was taken to the general hospital where all the routine tests and CT Scan head failed to reveal the cause.[ncbi.nlm.nih.gov]

Workup

Patients must be promptly evaluated through a detailed examination of the eye [5]. IOP of more than 30 mmHg (physiological range is between 10 and 23 mmHg) is encountered in virtually all patients suffering from glaucoma, while other findings include a fixed mid-dilated pupil (4-6 mm) that reacts poorly to direct illumination, a hazy cornea that may be edematous, hyperemia of the conjunctiva and a shallow anterior chamber [3]. The presence of adhesions between the iris and the angle structure, termed peripheral anterior synechiae (PAS), can cause obstruction of the trabecular meshwork and are frequently encountered in angle closure glaucoma patients as well [3]. These findings can be confirmed either by performing gonioscopy or through a slit-lamp examination [5], while more specialized techniques have been developed to confirm angle closure. Ultrasound biomicroscopy, which is able to acquire real-time images of structures that potentially cause obstruction of the canal, and anterior segment optical coherence tomography, used to evaluate the anterior chamber, are imaging methods that are recommended for glaucoma workup by more skilled ophthalmologists [5].

Treatment

  • Even if it does not represent the first choice of treatment, it can be taken into consideration when the topical treatment does not control the intraocular pressure (IOP) and iridotomy does not have a positive effect on the angle closure, especially in[ncbi.nlm.nih.gov]

Prognosis

  • Disc hemorrhages are not particularly rare in primary angle-closure glaucoma and may be a sign of a poor prognosis.[ncbi.nlm.nih.gov]
  • The prognosis for eyes with neovascular glaucoma is poor (see Fig. 10.20a and b). Trauma.[alpfmedical.info]
  • Comorbid pathology will increase the risk of complications (especially if additional treatment is needed) and result in a more guarded prognosis.[patient.info]

Etiology

  • In angle closure glaucoma, clear lens extraction represents an etiological treatment that takes into account the role of the lens in the pathogenesis of the disease.[ncbi.nlm.nih.gov]
  • PREOPERATIVE CONSIDERATIONS Determine the etiology. Of first importance is to determine the underlying etiology of angle narrowing, as the approach to cataract surgery will differ depending on the pathology.[crstodayeurope.com]
  • Our report highlights the importance of recognizing the often multifactorial etiology of angle closure glaucoma to help guide clinical management.[dovepress.com]

Epidemiology

  • We discuss these findings together with other related epidemiological factors.[ncbi.nlm.nih.gov]
  • 12 December 2014 Research on the epidemiology and mechanisms of angle-closure glaucoma has influenced understanding, guidelines and clinical management of the condition around the world.[ucl.ac.uk]
  • Broad MeSH terms and keywords were used combining terms related to epidemiology (including MeSH search using exp prevalence *, and exp epidemiology *, and keyword search using words prevalence , epidemiology , and incidence ), terms related to disease[journals.plos.org]
  • Reprints: Yuan Bo Liang, MD, PhD, Clinical & Epidemiological Eye Research Center, The Affiliated Eye Hospital of Wenzhou Medical University, No. 270 West College Rd, Wenzhou, Zhejiang 325027, China (e-mail: yuanboliang@gmail.com ).[journals.lww.com]
  • Department of Epidemiology & International Eye Health UCL Institute of Ophthalmology London UK[link.springer.com]
Sex distribution
Age distribution

Pathophysiology

  • This report presents the diagnosis, pathophysiologic mechanism, and management of a patient with both high myopia and bilateral advanced phacomorphic angle-closure glaucoma caused by isolated spherophakia.[ncbi.nlm.nih.gov]

Prevention

  • Targeting the lens and the angle structures and adjacent tissues simultaneously may be a promising approach in both the prevention of further angle closure, modulating the pressure, and prevention of cataract progression.[ncbi.nlm.nih.gov]

References

Article

  1. Porter RS, Kaplan JL. Merck Manual of Diagnosis and Therapy. 19th Edition. Merck Sharp & Dohme Corp. Whitehouse Station, N.J; 2011.
  2. Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson J, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 18e. New York, NY: McGraw-Hill; 2012.
  3. Pokhrel PK, Loftus SA. Ocular emergencies. Am Fam Physician. 2007;76(6):829.
  4. Azuara-Blanco A, Burr J, Ramsay C, Cooper D, Foster PJ, Friedman DS, et al. Effectiveness of early lens extraction for the treatment of primary angle-closure glaucoma (EAGLE): a randomised controlled trial. Lancet. 2016;388(10052):1389-1397.
  5. Weinreb RN, Aung T, Medeiros FA. The Pathophysiology and Treatment of Glaucoma: A Review. JAMA. 2014;311(18):1901-1911.

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Last updated: 2019-06-28 10:44