3/17/2016

AcuteAngleClosureGlaucomaClinicalPresentation:History,Physical,Causes

AcuteAngleClosureGlaucomaClinicalPresentation
Author:JosephFreedman,MDChiefEditor:StevenCDronen,MD,FAAEMmore...
Updated:Oct27,2015

History
Classically,patientsareelderly,sufferfromhyperopia,andhavenohistoryof
glaucoma.Mostcommonly,theypresentwithperiorbitalpainandvisualdeficits. [8]
Thepainisboringinnatureandassociatedwithanipsilateralheadache.Patients
noteblurryvisionanddescribethephenomenonof"seeinghalosaroundobjects."
Carefulinvestigationmayelucidateaprecipitatingfactor,suchasdimlightor
medications(eg,anticholinergics,sympathomimetics).
Inalargepercentageofpatients,extraocularsymptomsandsystemic
manifestationsarethechiefcomplaint.Patientspresentwithheadacheandmay
receivemedicationsformigrainesoranevaluationforasubarachnoidhemorrhage.
Severalcasereportsdiscusspatientspresentingwithvomitingandabdominalpain
thatweremisdiagnosedwithgastroenteritis. [9]

Physical
Theemergencydepartmentevaluationoftheeyeincludesvisualacuity,theexternal
eye,visualfields,afunduscopicexamination,pupils,ocularmotility,andIOP.Allof
thesetendtobeaffectedinAACG.
Slitlampevaluationmayrevealcornealedema,synechiae,irregularpupilshapeor
function,orsegmentalirisatrophy.
Patientscomplainofblurredvision,andtestingrevealstheabilityonlytodetect
handmovements.Theyareunabletoidentifynumbersandlettersondistance
chartsornearcards.
Corneaandscleralinjectionandciliaryflusharepresent.Theobviouslyedematous
andcloudycorneaobscuresthefunduscopicexamination.
IncreasedIOP(normallimit,1020mmHg)andischemiaresultinpainoneye
movement,amiddilatednonreactivepupil,andafirmglobe.Cliniciansmusttakea
comprehensivehistoryandperformathoroughphysicalexaminationtoensurethat
thistimesensitivediagnosisisnotmissed.

Causes
Shalloweranteriorchambersanteriorlysituatedlensshorteraxialeyelengththick
irisoverdevelopedirisdilatormusclesandanarrowangleleadtoahigher
propensityfordevelopmentofAACG.
Precipitatingfactorsincludedrugs(ie,sympathomimetics,anticholinergics,
antidepressants[SSRIs],anticonvulsants,sulfonamides,cocaine,botulinumtoxin),
[10,11,12,13,14]dimlight,andrapidcorrectionofhyperglycemia.
CasereportshaveidentifiedAACGassociatedwithcarotidcavernoussinusfistula,
trauma,pronesurgicalpositioning,andgiantcellarteritis. [14,15,16]
DifferentialDiagnoses

ContributorInformationandDisclosures
Author
JosephFreedman,MDResidentPhysician,DepartmentofEmergencyMedicine,StateUniversityofNewYork
Downstate,King'sCountyHospitalCenter
JosephFreedman,MDisamemberofthefollowingmedicalsocieties:EmergencyMedicineResidents&#039
Association
Disclosure:Nothingtodisclose.
Coauthor(s)
RichardHSinert,DOProfessorofEmergencyMedicine,ClinicalAssistantProfessorofMedicine,Research
Director,StateUniversityofNewYorkCollegeofMedicineConsultingStaff,ViceChairinChargeofResearch,
DepartmentofEmergencyMedicine,KingsCountyHospitalCenter
RichardHSinert,DOisamemberofthefollowingmedicalsocieties:AmericanCollegeofPhysicians,Society
forAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
AndrewAherne,MDResidentPhysician,DepartmentofEmergencyMedicine,KingsCountyHospitalCenter,

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3/17/2016

AcuteAngleClosureGlaucomaClinicalPresentation:History,Physical,Causes

UniversityHospitalofBrooklyn
Disclosure:Nothingtodisclose.
SpecialtyEditorBoard
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:ReceivedsalaryfromMedscapeforemployment.for:Medscape.
DouglasLavenburg,MDClinicalProfessor,DepartmentofEmergencyMedicine,ChristianaCareHealth
Systems
DouglasLavenburg,MDisamemberofthefollowingmedicalsocieties:AmericanSocietyofCataractand
RefractiveSurgery
Disclosure:Nothingtodisclose.
ChiefEditor
StevenCDronen,MD,FAAEMChair,DepartmentofEmergencyMedicine,LeConteMedicalCenter
StevenCDronen,MD,FAAEMisamemberofthefollowingmedicalsocieties:AmericanAcademyof
EmergencyMedicine,SocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
Acknowledgements
AyimKDarkeh,MDAssistantProfessor,DepartmentofEmergencyMedicine,StateUniversityofNewYork
DownstateMedicalCenter
AyimKDarkehisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergencyPhysicians,
EmergencyMedicineResidentsAssociation,NationalMedicalAssociation,andSocietyforAcademicEmergency
Medicine
Disclosure:Nothingtodisclose.
MichelleErvin,MDChair,DepartmentofEmergencyMedicine,HowardUniversityHospital
MichelleErvin,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofEmergencyMedicine,
AmericanCollegeofEmergencyPhysicians,AmericanMedicalAssociation,NationalMedicalAssociation,and
SocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
MarkASilverberg,MD,MMB,FACEPAssistantProfessor,AssociateResidencyDirector,Departmentof
EmergencyMedicine,StateUniversityofNewYorkDownstateCollegeofMedicineConsultingStaff,
DepartmentofEmergencyMedicine,StatenIslandUniversityHospital,KingsCountyHospital,University
Hospital,StateUniversityofNewYorkDownstateMedicalCenter
MarkASilverberg,MD,MMB,FACEPisamemberofthefollowingmedicalsocieties:AmericanCollegeof
EmergencyPhysicians,AmericanMedicalAssociation,CouncilofEmergencyMedicineResidencyDirectors,and
SocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.

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