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].

• 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]

• 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]

• 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]

• 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]

• 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]

  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]

  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]

• 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]

• 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]

  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]

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].

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.