Acute Closed Angle Glaucoma


Article Author:
Babak Khazaeni


Article Editor:
Leila Khazaeni


Editors In Chief:
Casey Ciresi


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
6/3/2019 5:24:19 PM

Introduction

Glaucoma is a set of ocular disorders often defined by increased intraocular pressures leading to optic neuropathy and vision loss if untreated.[1] Glaucoma has traditionally been classified as open-angle or closed-angle and as primary or secondary. The angle refers to the angle between the iris and the cornea in the anterior chamber which can become structurally obstructed. By definition, primary glaucomas are not associated with known ocular or systemic disorders and usually affect both eyes. Secondary glaucomas are associated with ocular or systemic disorders and are often unilateral. Acute angle-closure glaucoma is a subset of primary angle-closure glaucoma.

The commonly accepted range for intraocular pressure is 10-22 mm Hg. Three factors affect intraocular pressure:  the rate of production of aqueous humor by the ciliary body, the resistance to aqueous outflow through the trabecular meshwork and Schlemm’s canal, and the episcleral venous pressure. The normal flow of aqueous humor starts in the ciliary body, goes through the pupil and out through the trabecular meshwork and Schlemm's canal in the angle of the anterior chamber.  In acute angle closure glaucoma, intraocular pressure increases rapidly due to outflow obstruction of the aqueous humor.  There are several factors leading to the obstruction in acute angle closure glaucoma, but the major predisposing factor is the structural anatomy of the anterior chamber leading to a shallower angle.[2]

Etiology

Blockage of the aqueous humor occurs due to a number of predisposing anatomic variations.  These variations include a shallower anterior chamber, lens size, anterior location of the iris-lens diaphragm, and a narrow entrance to the anterior chamber angle.  The shallower anterior chamber angle leads to a large area of the iris and lens being in contact with each other slowing the flow of aqueous humor from the posterior chamber to the anterior chamber. This, in turn, leads to a pressure differential between the chambers called a pupillary block.[3]  The pupillary block causes bowing of the iris which narrows the angle of the anterior chamber further.  This cycle will perpetuate increasing intraocular pressures leading to the clinical presentation of acute angle closure glaucoma.

Epidemiology

There are a number of risk factors for acute angle closure glaucoma which include age, gender, race and family history.[4]

  • Age: Average age at presentation is 60 and prevalence increases thereafter. This is felt to be due to the increasing size of the lens with age.
  • Gender: There is a 4:1 ratio of the incidence of angle closure glaucoma in women versus men.
  • Race: Angle-closure glaucoma is more common in Southeast Asians, Chinese, and Eskimos. It is uncommon in black populations.  In whites, acute angle closure glaucoma accounts for 6% of all glaucoma diagnoses.[5]
  • Family history: Ocular anatomic features are inherited. 

Pathophysiology

An acute attack of angle closure glaucoma is precipitated by pupillary dilatation leading to increasing iris and lens contact increasing the pupillary block.[6]  The increasing pupillary block leads to bulging of the iris acutely closing the angle between the iris and cornea thus obstructing the aqueous humor outflow track.  The intraocular pressure rises acutely leading to symptomology.

History and Physical

Acute angle closure glaucoma presents as a sudden onset of severe unilateral eye pain or a headache associated with blurred vision, rainbow-colored halos around bright lights, nausea, and vomiting.[7]  The physical exam will reveal a fixed midpoint pupil and a hazy or cloudy cornea with marked conjunctival injection (most prominent at the limbus).  Intraocular pressure will be elevated and can be as high as 60 to 80 mm Hg in an acute attack.  A mild amount of aqueous flare and cell may be seen.  The optic nerve may also be swollen during an acute attack.

Evaluation

Measuring an elevated intraocular pressure is diagnostic.  There is no need for any imaging studies.  A basic metabolic panel should be checked if osmotic agents will be initiated for treatment.  A gonioscopic examination by an ophthalmologist to verify angle closure makes the definitive diagnosis.  Gonioscopy of the unaffected eye will reveal a narrow occludable angle given the anatomic predisposing factors to acute angle-closure glaucoma (See other issues for further discussion). Glaucomflecken (grey-white opacities on the anterior lens capsule) may be visible if previous attacks of angle-closure glaucoma have occurred.

Treatment / Management

The medical treatment for acute angle closure glaucoma aims to decrease the intraocular pressure by blocking the production of aqueous humor, increasing the outflow of aqueous humor and reducing the volume of the aqueous humor.[8][9]

Initial medical therapy includes a combination of the following medications:

  • Intravenous acetazolamide 500 mg to block the production of aqueous humor.
  • Intravenous mannitol 1-2 grams/kg can be given (if there is no contraindication) to rapidly reduce the volume of aqueous humor.
  • Topical Beta-Blocker (Timolol 0.5%) one drop to block the production of aqueous humor.
  • Topical Alpha 2-Agonist (Apraclonidine 1%) one drop to block the production of aqueous humor.
  • Topical Pilocarpine 1%-2% one drop every 15 minutes for two doses once intraocular pressure is below 40 mm Hg to increase the outflow of aqueous humor.  This is not effective at higher pressures due to pressure-induced ischemic paralysis of the iris.

Intraocular pressure needs to be checked every hour.

Emergently consult ophthalmology as you begin treatment.

Definitive treatment is peripheral iridectomy after the acute episode subsides.  Laser iridectomy is the treatment of choice.  Surgical iridectomy is indicated when laser can not be accomplished.  Iridectomy relieves the pupillary block as the pressure between the posterior and anterior chamber approaches zero by allowing the flow of aqueous humor through a different route.  Iridectomy should be as peripheral as possible and covered by the eyelid to avoid monocular diplopia through this second hole in the pupil. 

Pearls and Other Issues

An untreated fellow eye has a 40-80% chance of developing an acute attack angle-closure glaucoma over 5-10 years as it shares the same anatomic predisposing factors of the first eye.[10]  Hence peripheral iridectomy should be performed in the fellow eye as well as the affected eye.

The gender and ethnicity predisposing factors to acute angle-closure glaucoma hint at a genetic predisposition to the disease in certain populations.  Recent large-scale studies have shown a clear association to several genes and genetic loci with primary open-angle glaucoma, but evidence for acute angle-closure glaucoma is sparse.  So far only one study has shown a genetic locus on Chromosome 11 that can cause acute angle-closure glaucoma.

Enhancing Healthcare Team Outcomes

Acute angle closure glaucoma is best managed by a multidisciplinary team that also includes an ophthalmology nurse and the pharmacist. After managing the emergency with eyedrops, the patient should be scheduled for iridectomy. Clinicians need to be aware that the other eye is also at risk for acute angle close glaucoma and prophylactic surgery is recommended.

The outcomes for patients with acute angle closure glaucoma are good after treatment, however, delay in treatment can lead to damage to the optic nerve and vision loss.


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Acute Closed Angle Glaucoma - Questions

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A 64-year-old Inuit male presents to the emergency department with intense right eye pain, blurred vision, and nausea. The patient had been scheduled for a peripheral iridotomy with his previous ophthalmologist but did not go to his scheduled appointment. On examination, the vision is 20/400 in the right eye and 20/40 in the left. The emergency department provider gets an error message when trying to use the tonometer to check intraocular pressure. On examination of the right eye, there is a diffuse conjunctival injection, corneal edema, and a fixed pupil. Which of the following medication works to treat this disease by altering the anatomy of the eye?



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A 66-year-old female presents to the ophthalmology clinic for a new patient eye exam. The intraocular pressures are 32 in the right eye and 28 in the left eye. The angles of the eye are very narrow. Assuming no other medical conditions, what medication would be relatively contraindicated in this patient?



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A 65-year-old female has a sudden onset of right eye pain, nausea, and blurry vision when in the dark. She calls her optometrist's office, who sees her immediately. Her intraocular pressure is 58 in the right eye, and 21 in the left. What exam finding would be most specific for the most likely underlying etiology?



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A 76-year-old male presents to the emergency department with pain and blurry vision in his left eye. He has had multiple episodes of this in the past. His intraocular pressure is measured at 25 in the right eye and 48 in the left eye. On exam of the left eye, his angle appears extremely narrow and the eye is injected. What would be one of the first irreversible deficits that this patient would have as a result of this condition?



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A 64-year-old Asian male presents to the emergency department with and extreme left sided headache, blurry vision, and left eye redness. These symptoms all started when the patient dimmed the lights before going to bed. On ocular exam, the patient appears to have an extremely narrow angle in the left eye. Which of the following physical exam signs would be consistent with the most likely diagnosis?



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A 39-year-old female with a history of migraines presents with a right-sided headache, which she has had for the past 2 hours. The pain is localized around her right eye. The patient also reports decreased vision in the right eye, light sensitivity, and nausea. On exam, the patient has a fixed, mid-dilated pupil on the right and the eye is diffusely injected. What symptom is most concerning that this patient may have a disease other than a migraine headache?



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86-year-old presents to the eye clinic with complaints of left eye pain, headache, and blurry vision. Physical exam reveals scleral and corneal injection with a ciliary flush. The pupil is mid-dilated and nonreactive, and the globe appears firm. Which of the following would be a suitable starting topical medication?



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A 72-year-old female presents to the ophthalmologist’s office for an emergency department follow up visit for an episode of acute right eye pain and blurred vision with associated elevated intraocular pressure. On exam, the patient is found to have anatomically narrow angles. What would be the patient’s most likely prescription in the right eye?



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A 68-year-old woman presents to the emergency department complaining of severe left-sided facial and eye pain, loss of vision, colored halos around lights, nausea, and vomiting. On examination, her right eye is red, and the pupil is fixed and dilated. What would be the most appropriate next test?



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A patient arrives at the emergency department with complaints of sudden left eye pain, blurred and decreased vision, headache, and redness of the eye. The patient is nauseous, has vomited once, and sees halos around bright lights. The pain is 9/10. An exam reveals a fixed, mid-dilated pupil. How does the nurse proceed? Select all that apply.



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Closed-angle glaucoma is characterized as the obstruction of the flow of aqueous humor by a closed iridocorneal angle, which results in increased intraocular pressure. This increase in pressure within the eye causes the degeneration of the peripheral axons of the optic disc, resulting in optic cupping. In patients with closed-angle glaucoma, what cells of the retina are damaged?



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A 65-year-old woman presents with left-sided headache, nausea, and vomiting. On examination, she has an injected left eye with a cloudy cornea and fixed midpoint pupil. Tonometry reveals a pressure of 60 mmHg in the left eye. Which treatment will be effective at this point in the care of this patient?



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A 75-year-old man presents with headache, abdominal pain, nausea, and vomiting. On exam, he has a red right eye with a fixed midpoint pupil. Which of the following is the best initial test for this patient?



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A 73-year-old woman with no past medical history presents with right-sided headache, nausea, and vomiting. Her exam reveals an injected right eye with a cloudy cornea and fixed midpoint pupil. Her ocular pressure in the right eye is 50 mmHg. What is the best initial treatment for this patient?



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Acute Closed Angle Glaucoma - References

References

Primary Angle Closure Preferred Practice Pattern(®) Guidelines., Prum BE Jr,Herndon LW Jr,Moroi SE,Mansberger SL,Stein JD,Lim MC,Rosenberg LF,Gedde SJ,Williams RD,, Ophthalmology, 2016 Jan     [PubMed]
The physiologic characteristics of relative pupillary block., Anderson DR,Jin JC,Wright MM,, American journal of ophthalmology, 1991 Mar 15     [PubMed]
Primary angle closure glaucoma: What we know and what we don't know., Sun X,Dai Y,Chen Y,Yu DY,Cringle SJ,Chen J,Kong X,Wang X,Jiang C,, Progress in retinal and eye research, 2016 Dec 28     [PubMed]
Number of People Blind or Visually Impaired by Glaucoma Worldwide and in World Regions 1990 - 2010: A Meta-Analysis., Bourne RR,Taylor HR,Flaxman SR,Keeffe J,Leasher J,Naidoo K,Pesudovs K,White RA,Wong TY,Resnikoff S,Jonas JB,, PloS one, 2016 Oct 20     [PubMed]
Biometric Factors Associated With Acute Primary Angle Closure: Comparison of the Affected and Fellow Eye., Atalay E,Nongpiur ME,Baskaran M,Sharma S,Perera SA,Aung T,, Investigative ophthalmology & visual science, 2016 Oct 1     [PubMed]
Assessment and management of patients with acute red eye., Watkinson S,, Nursing older people, 2013 Jun     [PubMed]
Emergencies in glaucoma: a review., Collignon NJ,, Bulletin de la Societe belge d'ophtalmologie, 2005     [PubMed]
An Overview of Treatment Methods for Primary Angle Closure., Anwar F,Turalba A,, Seminars in ophthalmology, 2017     [PubMed]
Pohl H,Tarnutzer AA, Acute Angle-Closure Glaucoma. The New England journal of medicine. 2018 Mar 8;     [PubMed]
Ahram DF,Alward WL,Kuehn MH, The genetic mechanisms of primary angle closure glaucoma. Eye (London, England). 2015 Oct;     [PubMed]

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