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].

Skin
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  • Eyes
    Eye Pain
    • Some early symptoms in people at risk for angle-closure glaucoma include blurred vision, halos in their vision, headache, mild eye pain or redness.[sharecare.com]
    • Symptoms of angle-closure glaucoma may include headaches, eye pain, nausea, rainbows around lights at night, and very blurred vision.[glaucoma.org]
    • Two hours later, IOP fell further to 39 mmHg OD and 18 mmHg OS, and the patient’s eye pain improved.[care.diabetesjournals.org]
    • Acute angle-closure (closed-angle or narrow-angle) glaucoma produces symptoms such as eye pain , headaches, halos around lights, dilated pupils , vision loss, red eyes , nausea and vomiting.[allaboutvision.com]
    • Acute Angle-Closure Glaucoma Symptom Eye Pain Eye pain is often described as burning, sharp, shooting, dull, gritty, a feeling of "something in my eye," aching, pressure, throbbing, or stabbing.[emedicinehealth.com]
    Blurred Vision
    • If the ensuing rise in pressure is sudden, pain, blurred vision, and nausea may occur.[emedicinehealth.com]
    • Some early symptoms in people at risk for angle-closure glaucoma include blurred vision, halos in their vision, headache, mild eye pain or redness.[sharecare.com]
    • Symptoms of angle-closure glaucoma may include headaches, eye pain, nausea, rainbows around lights at night, and very blurred vision.[glaucoma.org]
    • 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]
    • This may cause pressure-induced corneal edema (experienced as blurred vision and occasionally as multicolored halos around lights) vascular congestion, eye pain, or headache.[ejournalofophthalmology.com]
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  • psychiatrical
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  • musculoskeletal
    Decrease in Height
    • Decreased corneal height. 40. 08/22/15 7.Anterior position of the lens with respect to the ciliary body. 8.[slideshare.net]
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  • neurologic
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  • Face, Head & Neck
    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]
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  • Entire body system
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  • 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].

    Laboratory

    Serum
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  • Microbiology
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  • Test Results

    Ocular Tonometry
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  • Visual Field Test
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  • Treatment

    Prognosis

    Complications

    Loss of Vision
    • This prevents or slows further loss of vision in most patients.[glaucoma-association.com]
    • It is an emergency because if it is not treated quickly, it can lead to permanent loss of vision.[patient.info]
    • An acute attack is a medical emergency and requires immediate treatment to prevent permanent loss of vision.[theglaucomaguide.com]
    • PACG is often missed in these populations, and efforts must be taken to identify it so that needless loss of vision is avoided.[reviewofoptometry.com]
    • Complications These include permanent loss of vision, repetition of the acute attack, attack in the fellow eye and central retinal artery or vein occlusion.[patient.info]
    Glaucoma
    • Open-angle glaucoma; Chronic glaucoma; Chronic open-angle glaucoma; Primary open-angle glaucoma; Closed-angle glaucoma; Narrow-angle glaucoma; Angle-closure glaucoma; Acute glaucoma; Secondary glaucoma; Congenital glaucoma; Vision loss - glaucoma Glaucoma[mountsinai.org]
    • Types of Glaucoma Open-angle glaucoma Angle-closure glaucoma Neovascular glaucoma Pigmentary glaucoma Pseudoexfoliation glaucoma Inflammatory glaucoma Open-angle Glaucoma Primary open-angle glaucoma is the most common form of glaucoma in America and Europe[ccfs2020.com]
    • In Asia, angle-closure glaucoma is more common than open-angle glaucoma.[emedicinehealth.com]
    • 2016 2017 2018 Non-Billable/Non-Specific Code Type 1 Excludes absolute glaucoma ( H44.51- ) congenital glaucoma ( Q15.0 ) traumatic glaucoma due to birth injury ( P15.3 ) Glaucoma H40.2 ICD-10-CM Diagnosis Code H40.2 Primary angle-closure glaucoma 2016[icd10data.com]
    • The detection of secondary angle closure glaucoma, like other forms of symptomless glaucoma, depends on regular routine eye examinations which include all three glaucoma tests .[glaucoma-association.com]
    Secondary Glaucoma
    • SECONDARY GLAUCOMA If you have secondary glaucoma, treating the cause may help your symptoms go away.[mountsinai.org]
    • Keywords: angle closure glaucoma, plateau iris, topiramate, secondary glaucoma, drug-induced glaucoma This work is published and licensed by Dove Medical Press Limited.[dovepress.com]
    • During these visits, make sure you ask the optometrist (optician) to carry out the three glaucoma tests In all forms of secondary glaucoma the underlying condition is addressed if possible, and because the loss of vision in glaucoma is permanent, glaucoma[glaucoma-association.com]
    • Other, less common types of glaucoma are secondary glaucoma and congenital glaucoma.[patient.info]
    • Other types of glaucoma include: acute angle closure glaucoma – an uncommon type caused by the drainage in the eye becoming suddenly blocked, which can raise the pressure inside the eye very quickly secondary glaucoma – caused by an underlying eye condition[nhs.uk]
    Appendicitis
    • Sometimes the stomach problem is so prominent that people go to an emergency room and the staff pays attention to that, thinking it is appendicitis, before realizing that the eye is the cause.[hopkinsmedicine.org]
    Interstitial Keratitis
    • keratitis — Posterior (pushing mechanism) With pupillary block Lens-induced mechanisms Intumescent lens Subluxation of lens Mobile lens syndrome Posterior synechiae Iris-vitreous block in aphakia Pseudophakia Uveitis Pupillary block glaucoma — Without[merckmanuals.com]

    Etiology

    Epidemiology

    Sex distribution
    Age distribution

    Pathophysiology

    Prevention

    Summary

    Patient Information

    Other symptoms

    Cimetidine
    • Gastrointestinal agents Cimetidine and ranitidine, H2-blocker agents, have weak anticholinergic adverse effects, which may induce AACG.[eyewiki.org]
    • Some medicines used to treat allergies or stomach ulcers, such as chlorphenamine , cimetidine and ranitidine .[patient.info]
    Laxative
    • In addition, it is postulated that the zonule becomes more lax with age, allowing anterior movement of the lens/iris diaphragm.[omicsonline.org]
    Iridocorneal Adhesions
    • Posterior polymorphous dystrophy Glaucoma occurs in 10–15% of patients -presents with corneal edema, iris atrophy, mild corectopia, and iridocorneal adhesions -maintain good vision throughout lives -cluster or linear arrangement of vesicles in the posterior[slideshare.net]

    Self-assessment

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    References

    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.

    1. Acute angle-closure glaucoma: the second eye: an analysis of 200 cases - RF Lowe - The British Journal of Ophthalmology, 1962 - ncbi.nlm.nih.gov
    2. Aetiology of the anatomical basis for primary angle-closure glaucoma. Biometrical comparisons between normal eyes and eyes with primary angle-closure glaucoma. - RF Lowe - The British journal of ophthalmology, 1970 - ncbi.nlm.nih.gov
    3. An ultrasound biomicroscopic analysis of angle-closure glaucoma secondary to ciliochoroidal effusion in IgA nephropathy. - CJ Pavlin, M Easterbrook, K Harasiewicz - American journal of , 1993 - ukpmc.ac.uk
    4. Angle-closure glaucoma in an urban population in southern India: the Andhra Pradesh Eye Disease Study - L Dandona, R Dandona, P Mandal - , 2000 - journals.elsevierhealth.com
    5. Acute angle-closure glaucoma following botulinum toxin injection for blepharospasm. - P Corridan, S Nightingale, N Mashoudi - British journal of , 1990 - bjo.bmj.com
    6. Acute myopia and angle-closure glaucoma induced by topiramate - M Boentert, H Aretz, P Ludemann - Neurology, 2003 - AAN Enterprises
    7. Severity and spatial distribution of visual field defects in primary glaucoma: a comparison of primary open-angle glaucoma and primary angle-closure glaucoma - G Gazzard, PJ Foster, AC Viswanathan - Archives of , 2002 - Am Med Assoc
    8. Acute angle closure glaucoma associated with nebulised ipratropium bromide and salbutamol. - P Shah, L Dhurjon, T Metcalfe - BMJ: British Medical , 1992 - ncbi.nlm.nih.gov
    9. Five‐year risk of progression of primary angle closure to primary angle closure glaucoma: a population‐based study - R Thomas, R Parikh, J Muliyil - Acta Ophthalmologica , 2003 - Wiley Online Library
    10. Anterior chamber depth measurement as a screening tool for primary angle-closure glaucoma in an East Asian population - JG Devereux, PJ Foster, J Baasanhu - Archives of , 2000 - Am Med Assoc

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