ACUTE ANGLE CLOSURE GLAUCOMA

Clinical features:

Ø  Patient presents acutely (congestive glaucoma) with coloured halos around lights due to corneal oedema, ocular pain and headache.

Ø  The IOP rise maybe often be so severe as to cause nausea and vomiting and mimic a case of acute abdomen.

Ø  Precipitating factors include watching television or movie in a darken room, reading, pharmacological mydriasis or miosis, acute emotional stress and rarely systemic medications like parasympathetic antagonists or sympathetic agonists (e.g. inhalers, motion sickness patches and cold remedies) and topiramate.

Ø  On examination, IOP is usually very high (> 40 - 50 mmHg) with conjunctival hyperaemia, corneal edema, unreactive mid dilated vertically oval pupil.

Ø  Fellow eye generally shows an occludable angle.

Pharmacological treatment:

1.       Treatment intensity should be individualized dependent on severity.

2.       Hospital admission is usually required in an acute presentation.

3.       The patient should assume a supine position to encourage the lens to shift posteriorly under the influence of gravity.

4.       Inj. mannitol 20% 1–2 g/kg intravenously over half hour or glycerol 50% 1 g/kg orally, having checked for contraindications.

5.       Pilocarpine 2–4% one drop to the affected eye, repeated after half an hour, and one drop of 1% as prophylaxis into the fellow eye. Some practitioners prefer to omit pilocarpine in an acutely presenting eye with very high IOP until a significant IOP fall has taken place, as the associated ischaemia will compromise the action of pilocarpine on the pupillary sphincter and it may also aggravate the pupillary block.

6.       An additional oral dose of Tab. acetazolamide 500 mg may be given.

7.       Topical timolol 0.5%, prednisolone 1% or dexamethasone 0.1% to the affected eye, leaving 5 minutes between each instillation.

8.       Analgesia and an antiemetic may often be required. Subsequent medical treatment

9.       Pilocarpine 2% QID to the affected eye and 1% QID to the fellow eye.

10.    Topical steroid (prednisolone 1% or dexamethasone 0.1% QID) if the eye is acutely inflamed.

Any or all of the following should be continued as necessary according to response: timolol 0.5% BD and oral acetazolamide 250 mg QID may be required.

11.    Surgical treatment:

Definitive treatment is laser iridotomy or iridoplasty after corneal oedema clears. Topical steroids and any necessary hypotensives can be continued for at least a week. Surgical options in resistant cases include surgical peripheral iridectomy, lens extraction, goniosynechialysis and trabeculectomy.

Patient education:

u  Do not ignore headache or chronic ache in the eyes and report to the ophthalmologist if coloured halos around light appear.