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].

• Pain

  The patient presented with a two-day history of left eye pain, acutely reduced vision and a nine-month history of hemicranial pain. Examination identified left intraocular pressure (IOP) of 52mmHg. Gonioscopy confirmed complete angle closure. [ncbi.nlm.nih.gov]

  She rated the pain as a “9” out of “10” on a pain scale; she described the pain as constant, with throbbing behind her left eye. There was no pain associated with extraocular movements. [mdedge.com]

  Diagnosis Diagnosis of AAC is based on at least two of these symptoms: Ocular pain. Nausea/vomiting. [patient.info]

• Severe Pain

  He was suffering from severe pain and vision loss in his right eye. Findings on examination were hyperemia, proptosis, and myopia measuring approximately 6 diopters. [ncbi.nlm.nih.gov]

  EyeRounds Online Atlas of Ophthalmology Contributor: Andrew Doan, MD, PhD, University of Iowa Category: Glaucoma / Iris 1) Patient awoke with severe pain OD, headache, decreased vision OD, and nausea. Photo shows unilateral redeye with hazy cornea. [webeye.ophth.uiowa.edu]

• Fever

  To report a case of bilateral simultaneous angle-closure glaucoma caused by septic condition of Korean hemorrhagic fever. A 62-year-old man visited our emergency center with signs of sepsis (fever, leukocytosis, and oliguria). [ncbi.nlm.nih.gov]

  She denied systemic symptoms including dizziness, nausea, vomiting, malaise, neck stiffness, fever, or any focal neurological complaints. Her last dose of topiramate was 25 mg, 20 hours prior to presentation. [bmcpediatr.biomedcentral.com]

• Collapse

  Post-traumatic presence of blood or exudate in the angle of the anterior chamber and prolonged contact between the iris and trabecular mesh-work in a collapsed anterior chamber (following injury, surgery, or insufficient treatment of primary angle closure [alpfmedical.info]

  The mechanism involves a collapse forward within the eye of the gel called the vitreous that fills the back two thirds of the eye cavity. [hopkinsmedicine.org]

• Fatigue

  In comparison with the one other case of pediatric ACG from topiramate [ 16 ], our patient did not present with headache, nausea, and fatigue, had a slightly lower IOP (40 vs. 50 mmHg), did not show microcystic corneal edema, but did have iridocornreal [bmcpediatr.biomedcentral.com]

• 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]

• Hypertension

  Abstract Primary angle-closure glaucoma (PACG) is a progressive optic nerve degeneration and is defined as a glaucomatous optic neuropathy with associated characteristic enlargement of optic disc cupping and visual field loss that is secondary to ocular hypertension [ncbi.nlm.nih.gov]

  She is hypertensive, while the remainder of her vital signs are unremarkable. On exam, she has scleral injection, a hazy cornea, and mid-dilated, fixed pupil. The globe itself feels rock hard on palpation. [emdocs.net]

  The results from a large published study showed that if you have ocular hypertension without glaucoma you still may benefit from glaucoma treatment. [patient.co.uk]

  Glaucoma can occur at ‘normal’ intraocular pressures, and other patients appear unaffected by chronic intraocular hypertension. Q10. What is shown above? Answer and interpretation A pale, cupped optic disc — the hallmark of chronic glaucoma. Q11. [lifeinthefastlane.com]

  Postoperative ocular hypertension from use of alpha chymotrypsin. [en.wikipedia.org]

• 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]

  Dramatic symptoms of acute angle-closure glaucoma include the following: Severe eye pain Nausea and vomiting Headache Blurred vision and/or seeing haloes around lights (Haloes and blurred vision occur because the cornea is swollen.) [emedicinehealth.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]

  She rated the pain as a “9” out of “10” on a pain scale; she described the pain as constant, with throbbing behind her left eye. There was no pain associated with extraocular movements. [mdedge.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]

  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]

  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]

• Corneal Edema

  Intraocular pressures were 33 mmHg and 32 mmHg in the right and left eyes, respectively, with conjunctival chemosis, corneal edema, shallow anterior chambers, and closed angles. Her refraction was -7.50 diopters in both eyes. [ncbi.nlm.nih.gov]

  We have decided against a laser PI and are monitoring her angles every six months Topical steroids are helpful to relieve inflammation, and topical osmotic agents such as glycerin can reduce corneal edema and clear the cornea quickly if corneal edema [reviewofoptometry.com]

  A pressure that exceeds 21 mmHg characterizes elevated intraocular pressure, however the pressure may exceed 60-80 mmHg. 2 Fundoscopic examination is often difficult due to the presence of corneal edema; however, one of the most notable features is a [canadiem.org]

  It may also allow clearing of the corneal edema to facilitate LPI. Other reports recommend laser iridoplasty, corneal indentation, cataract or clear lens extraction. [aao.org]

• Excessive Tearing

  She continued to experience worsening vision accompanied with red eyes, swollen eyelids, excessive tearing and photophobia. She denied pain, burning, itching, mucus discharge, or pain with extraocular movements. [bmcpediatr.biomedcentral.com]

• Lacrimation

  Photosensitivity and increased lacrimation of the left eye were present, along with associated nausea. The patient denied any ocular trauma or previous surgery. [mdedge.com]

• 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]

• 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]

• Mydriasis

  PurposeTo ascertain the risk of angle closure glaucoma associated with mydriasis in the Northern Ireland Diabetic Retinopathy Screening Programme.MethodsA retrospective case note review was carried out, cross referencing hospital records with those of [ncbi.nlm.nih.gov]

  Respiratory agents Epinephrine may cause mydriasis and precipitate AACG in susceptible individuals. Ipratropium bromide, an anticholineric agent causes mydriasis and might precipitate an AACG event. [eyewiki.org]

  Pupillary dilation (mydriasis) can push the iris into the angle and precipitate acute angle-closure glaucoma in any person with narrow angles. [merckmanuals.com]

• Confusion

  Terminology to describe PACG is confusing, and this lack of clarity influences how we think about the disease. Much of this confusion stems from the literature that developed when gonioscopy first became widely available in the 1950s. [reviewofoptometry.com]

  Sometimes pain originating from the eye is confused with other symptoms, such as a headache, sinus pain, toothache, or a migraine. [emedicinehealth.com]

  During indentational maneuvers, iris processes must not be confused with PAS. [omicsonline.org]

  Nomenclature and Classification Historically the angle-closure glaucoma nomenclature has been confusing: conditions were sometimes classified by the time course of the disease, sometimes by the effects of the angle closure, and sometimes by the presumptive [slideshare.net]

• Seizure

  Later, it was approved for seizures associated with Lennox-Gastaut syndrome, generalized tonic clonic seizures, and as initial monotherapy for partial onset or primary generalized epilepsy. [bmcpediatr.biomedcentral.com]

  This case presents a 7-year-old who had recently begun topiramate therapy for seizures and headache. She developed painless blurred vision and acute bilateral myopia, which progressed to acute bilateral angle closure glaucoma. [ncbi.nlm.nih.gov]

  Also, a prescription drug for seizures, topiramate (Topamax, Ortho-McNeil) can cause angle-closure glaucoma even in patients with an initial open-angle configuration. [reviewofophthalmology.com]

• Stroke

  The edges of the incision are then stroked to encourage the iris to retract into the anterior chamber, and the corneal incision is closed with one or two 10-0 nylon sutures. [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].

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]

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]

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]

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: [email protected] ). [journals.lww.com]

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]

M. (2011) - Epidemiology of canine glaucoma presented to University of Zurich from 1995 to 2009. Part 1: Congenital and primary glaucoma (4 and 123 cases). Vet. Ophthalmol. 14, 121–126. STROM A. R., HÄSSIG M., IBURG T. M. & SPIESS B. [genodog.fr]

We discuss these findings together with other related epidemiological factors. [ncbi.nlm.nih.gov]

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]

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]

This review asks whether ACG can be prevented on a population basis. [nature.com]

How can I help prevent glaucoma? Glaucoma cannot be prevented. However, blindness can be prevented if glaucoma is treated before pressure in the eye has damaged the optic nerve too much. [summitmedicalgroup.com]

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.