Acute Angle-closure Glaucoma | Symptoms and Treatment

Structure (anatomy) of your eye

You can learn more about how the eye works and the structure of the eye in the separate leaflet called Anatomy of the eye. Glaucoma is mainly to do with the fluid in the eye, called aqueous humour, not being able to drain away properly.

What is acute angle-closure glaucoma?

Dr Sarah Jarvis MBE

Acute angle-closure glaucoma occurs when the flow of aqueous humour out of the eye is blocked and pressure inside the eye becomes too high very quickly. It is an emergency because if it is not treated quickly, it can lead to permanent loss of vision. Acute angle-closure glaucoma is also sometimes referred to as acute closed-angle glaucoma or just acute glaucoma. For ease, this leaflet will use the term ‘acute glaucoma’.

There are other types of glaucoma which occur more gradually. The most common type is chronic open-angle glaucoma (also called primary open-angle glaucoma or simply chronic glaucoma). See the separate leaflet called Chronic Open-angle Glaucoma for details.

Other, less common types of glaucoma are secondary glaucoma and congenital glaucoma. ‘Congenital’ means that it is present from birth. The rest of this leaflet deals only with acute glaucoma.

What causes acute angle-closure glaucoma?

In acute glaucoma there is a sudden blockage of drainage of aqueous humour fluid out of your eye. As more fluid continues to be made, the pressure inside your eye rises quickly. This can start to damage the optic nerve at the back of the eye and vision can be affected.

What causes the blockage?

Some people are more prone to develop acute glaucoma because of the structure of their eye. For example, if the area near the base of the iris is very narrow, the trabecular meshwork can become blocked more easily. If the lens is thicker and sits further forward than normal, this can have the same effect. Both these cause what is known as a narrow drainage angle or a shallow anterior chamber and can make acute glaucoma more likely. In other people, the iris can be thinner and more floppy than usual, making it more likely to cause blockage of the trabecular meshwork.

The muscles of the iris control the size of your pupil. In someone who is prone to acute glaucoma the dilation of the pupil can mean their lens can ‘stick’ to the back of their iris. This blocks the route of the aqueous humour through the iris from the posterior chamber or through the pupil to the anterior chamber. The aqueous fluid collects behind the iris and causes the iris to bulge forwards and block the trabecular meshwork. This further prevents drainage of the aqueous fluid from their eye. The pressure within the eye rises rapidly. It is particularly likely to happen in people with a thinner, floppier iris or a shallow anterior chamber.

Can anything trigger acute glaucoma?

In people who are prone to acute glaucoma there are some situations that may trigger it. For example, acute glaucoma is more likely to come on when the pupil is dilated. This could be whilst watching television in dim light, during stress or excitement, or at night.

Some medicines can also trigger acute glaucoma in people prone to it, as can general anaesthetics in older people. For the population as a whole the chance of getting acute glaucoma with these medicines is extremely small, so they are commonly prescribed without serious concern. However, if you have been warned that you may be prone to acute glaucoma, you should tell your doctor before starting new medication or eye drops, especially if it is one on the list below.

Commonly used medicines which may trigger acute glaucoma are:

• Eye drops used to dilate the pupil – these may be used for eye check-ups.
• Antidepressants of the tricyclic or selective serotonin reuptake inhibitor (SSRI) types.
• Some of the medicines used to treat feeling sick (nausea), being sick (vomiting) or the mental health condition called schizophrenia. (There is a type of medicine called phenothiazines, one of which is chlorpromazine.)
• Ipratropium (used for asthma).
• Topiramate (used for migraines and epilepsy).
• Some medicines used to treat allergies or stomach ulcers, such as chlorphenamine, cimetidine and ranitidine.
• Medication used during a general anaesthetic.
• Steroid medicines (such as are used in asthma and emphysema) can sometimes cause high pressure in the eyes when used for long periods of time, but do not usually cause acute glaucoma.

Who develops acute angle-closure glaucoma?

About 1 in 1,000 people develop acute glaucoma in their lifetime, so thankfully it is a rare condition. It is more likely in people over the age of 40 years and most often happens at around age 60-70 years. It is more common in long-sighted people and in women. It is also more common in Southeast Asian and Inuit people.

If one of your close relatives (mother, father, sister or brother) has had acute glaucoma, you have an increased risk of developing it. This is because you may have inherited an eye shape which makes acute glaucoma more likely. If you have a positive family history like this you should speak with an optician regarding when, and how often, you should have eye checks.

What are the symptoms of acute angle-closure glaucoma?

The symptoms usually start suddenly. They include:

• Sudden, severe pain within one eye and an ache around your eye.
• Redness of your eye.
• Blurred or reduced vision, often with circles (haloes) seen around lights.
• The pain may spread around your head and be felt as a severe headache.
• Some people develop a feeling of sickness (nausea) and are sick (vomit).
• Your eye usually feels hard and tender.
• You may feel generally unwell.
• The clear surface of your eye (your cornea) can look hazy. 

This photo shows what the eye looks like in acute glaucoma:

Acute angle closure glaucoma of the right eye

James Heilman, MD, CC BY-SA 3. 0, via Wikimedia Commons

James Heilman, MD, CC BY-SA 3.0, via Wikimedia Commons

Symptoms may begin in a situation of dim lighting, sudden excitement, after taking certain medicines or after a general anaesthetic.

The symptoms usually continue to worsen unless treated and you should seek help immediately. Either an optician or an eye specialist (ophthalmologist) can make the diagnosis. A family doctor will able to recognise the symptoms and will know to send the person directly to hospital.

Some people have milder symptoms, sometimes with intermittent attacks of blurring and haloes without pain. The attack may end when they go into a brighter room. Both of these cause the pupil to constrict and pull the iris away from the drainage channels. This is called intermittent acute glaucoma. The attack of acute glaucoma can last for a few hours and then symptoms can improve again. However, attacks will usually happen again and, with each attack, your vision may be damaged further. If you have these symptoms you should see a doctor urgently, in case you need treatment to prevent a more severe attack. 

How is acute angle-closure glaucoma diagnosed?

The diagnosis is made from the symptoms and the appearance of your eye. A likely diagnosis may be made by your GP, by an emergency doctor or by an optician. The diagnosis is confirmed by an examination done by an eye specialist (an ophthalmologist). This usually involves examining your eye using a special light and magnifier called a slit lamp and measuring the pressure in your eye. A specialist can also use a gonioscope to directly examine the outflow channels around the trabecular meshwork area of your eye.

Acute angle-closure glaucoma treatment

Initial treatment

Quick treatment is needed for acute glaucoma. You should be seen by an eye specialist as soon as possible. If it will take time getting to the ophthalmologist, some treatment can be started.

You should not try to cover the affected eye with a patch or a blindfold. If you do this, your pupil will dilate further and this can worsen the situation. Don’t lie down in a darkened room – lying down can tend to raise the pressure in your eye still further. A darkened room will further dilate the pupil, making things worse.

The first treatment is medication to lower the pressure within your eye. There are various types of medicine and eye drops that may be used in different combinations. Treatments may include:

• Eye drops containing beta-blocker medication (to reduce fluid production in your eye) and steroids (to reduce inflammation) – for example, timolol.
• An injection of a medicine called acetazolamide.
• Pilocarpine eye drops which can cause your pupil to become smaller (constrict) and help to move the iris away from the trabecular meshwork. This helps to open up the obstruction to the flow of aqueous humour fluid.
• Other types of eye drops are also used, including steroid eye drops.
• Other fluid-reducing medication such as mannitol which is given into a vein (intravenously).

You may also be given painkillers and antisickness medication if needed.

Further treatment

When the pressure in your eye has gone down, further treatment is needed to prevent acute glaucoma from coming back. This involves using laser treatment or surgery to make a small hole in your iris. The hole allows fluid to flow freely around your iris and can stop the iris bulging forwards and blocking the trabecular meshwork in the future.

• Laser treatment is called peripheral iridotomy. This is the usual treatment. Usually two small holes are made in your iris, using a laser. The holes are almost unnoticeable to other people. Laser treatment is done using local anaesthetic in an outpatient clinic.
• Surgical treatment called surgical iridectomy is another option. A small, triangular hole is made in your iris. The hole is visible afterwards as a very small, black triangle at the edge of your iris.

Usually, laser or surgical treatment will be advised for the other eye, often at the same time. This is to prevent acute glaucoma in the other eye, which is otherwise quite likely. Sometimes eye drops are needed longer-term to help keep your eye pressure under control.

What is the outlook for acute angle-closure glaucoma?

The outlook (prognosis) is good if treatment is started quickly. Your eye can recover and laser treatment or surgery can prevent the problem coming back. If the attack is severe, or if treatment is delayed, the high pressure in your eye can damage the optic nerve and blood vessels. If this is the case, there is a risk that your vision will be permanently reduced in the affected eye.

Driving and glaucoma

Many people will be allowed to drive after recovering from acute angle-closure glaucoma. Even if vision is reduced in one eye, you may still be allowed to drive if your vision is good enough in the other eye. However, you will need advice from your eye specialist. If you are a driver in the UK and have glaucoma causing loss of vision in both eyes, you must by law inform the Driver and Vehicle Licensing Authority (DVLA). The DVLA will usually contact your eye specialist (ophthalmologist) and ask them for a report about your eye problems. They may also arrange an examination of your eyesight with an optician.

Can acute angle-closure glaucoma be prevented?

As mentioned above, some people have an increased risk of developing acute glaucoma because they have a shallow anterior chamber or narrow drainage angle. Sometimes this is noticed at a routine eye examination. You may be told about this and advised to be careful with certain medicines and eye drops (see above). If you are at very high risk of acute glaucoma, you may be advised to have preventative treatment such as laser iridotomy (see above).

Be aware of the symptoms of acute glaucoma. You should seek medical advice immediately if you develop a red eye with any of the following:

• Pain
• Being sick (vomiting)
• Reduced vision

If you take a new medication or have eye drops to enlarge (dilate) your pupil and then you develop symptoms of acute glaucoma, seek medical advice straightaway. Tell your doctor about the medication and symptoms. This makes it easier for the problem to be recognised early.

What causes acute angle-closure glaucoma (AACG)?

Author

Albert P Lin, MD Assistant Professor, Department of Ophthalmology, Baylor College of Medicine; Staff Physician, Michael E DeBakey Veterans Affairs Medical Center; Ophthalmologist, Ophthalmology Consultants of Houston

Albert P Lin, MD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, Harris County Medical Society, Texas Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Kristin Schmid Biggerstaff, MD, MS Associate Professor, Department of Ophthalmology, Baylor College of Medicine; Glaucoma Staff Physician, Michael E DeBakey Veterans Affairs Medical Center

Kristin Schmid Biggerstaff, MD, MS is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, American Society of Cataract and Refractive Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Martin B Wax, MD Professor, Department of Ophthalmology, University of Texas Southwestern Medical School; Vice President, Research and Development, Head, Ophthalmology Discovery Research and Preclinical Sciences, Alcon Laboratories, Inc

Martin B Wax, MD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, Society for Neuroscience

Disclosure: Nothing to disclose.

Chief Editor

Inci Irak Dersu, MD, MPH Associate Professor of Clinical Ophthalmology, State University of New York Downstate College of Medicine; Attending Physician, SUNY Downstate Medical Center, Kings County Hospital, and VA Harbor Health Care System

Inci Irak Dersu, MD, MPH is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society

Disclosure: Nothing to disclose.

Additional Contributors

Kilbourn Gordon, III, MD, FACEP Urgent Care Physician

Kilbourn Gordon, III, MD, FACEP is a member of the following medical societies: American Academy of Ophthalmology, Wilderness Medical Society

Disclosure: Nothing to disclose.

Robert J Noecker, MD, MBA Associate Professor, Department of Ophthalmology, University of Pittsburgh School of Medicine; Director, Glaucoma Service, Vice Chair, Department of Ophthalmology, University of Pittsburgh Medical Center Eye Center

Robert J Noecker, MD, MBA is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, American Glaucoma Society, American Medical Association, American Society of Cataract and Refractive Surgery

Disclosure: Received consulting fee from Allergan for consulting; Received grant/research funds from Allergan, Zeiss, Lumenis for other; Received honoraria from Allergan, Alcon, Lumenis, Endo-optics for speaking and teaching.

Malik Y Kahook, MD Clinical Instructor of Ophthalmology, Fellow in Glaucoma, Department of Ophthalmology, University of Pittsburgh Medical Center

Malik Y Kahook, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Association for Research in Vision and Ophthalmology, Colorado Medical Society

Disclosure: Received consulting fee from Alcon for consulting.

Glaucoma | AOA

The optic nerve is a bundle of about 1 million individual nerve fibers that transmits the visual signals from the eye to the brain. In the most common form of glaucoma, primary open-angle glaucoma, the fluid pressure inside the eye increases. This increase in pressure may cause progressive damage to the optic nerve and loss of nerve fibers. Advanced glaucoma may even lead to blindness. Not everyone with high eye pressure will develop glaucoma, and some people with normal eye pressure will develop glaucoma. When the pressure inside a person’s eye is too high for a particular optic nerve, whatever that pressure measurement may be, glaucoma will develop. Glaucoma is the second-leading cause of blindness in the U.S. It most often occurs in people over age 40, although an infant (congenital) form of glaucoma exists. People with a family history of glaucoma, African Americans over the age of 40 and Hispanics over the age of 60 have an increased risk of developing glaucoma. Other risk factors include thinner corneas, chronic eye inflammation and taking medications that increase the pressure in the eyes.

The most common form of glaucoma, primary open-angle glaucoma, develops slowly and usually without any symptoms. Many people are not aware they have the condition until they have significant vision loss. Initially, glaucoma affects peripheral or side vision, but it can advance to central vision loss. If left untreated, glaucoma can lead to significant vision loss in both eyes, and may even lead to blindness.

A less common type of glaucoma, acute angle-closure glaucoma, usually occurs abruptly due to a rapid increase of pressure in the eye. Its symptoms may include severe eye pain, nausea, redness in the eye, seeing halos or colored rings around lights and blurred vision. This is an emergency condition in which severe vision loss can occur quickly; see your doctor of optometry immediately. Glaucoma cannot currently be prevented. But if it is diagnosed and treated early, it can usually be controlled. Medication or surgery can slow or prevent further vision loss. However, vision already lost to glaucoma cannot be restored. That is why the American Optometric Association recommends an annual dilated eye examination for people at risk for glaucoma. Depending on your specific condition, your doctor may recommend more frequent examinations.

Causes & risk factors

There are many theories about the causes of glaucoma, but the exact cause is unknown. Although the disease is usually associated with an increase in fluid pressure inside the eye, other theories include a lack of adequate blood supply to the nerve.

The following are the different types of glaucoma and their potential causes.

Primary open-angle glaucoma

This is the most common form of glaucoma. Damage to the optic nerve is slow and painless. Those affected can lose a large portion of vision before they notice any vision problems. One theory about its development is that the eye’s drainage system becomes inefficient over time. This leads to an increased amount of fluid and a gradual buildup of pressure within the eye. Another theory about the cause of this type of glaucoma is that there is poor blood flow (perfusion) to the optic nerve. Other theories also exist.

Angle-closure glaucoma

This type of glaucoma, also called closed-angle glaucoma or narrow-angle glaucoma, is a less common form of the disease. It is a medical emergency that can cause vision loss within a day of its onset. It occurs when the drainage angle in the eye (formed by the cornea and the iris) closes or becomes blocked. Many people who develop this type of glaucoma have a very narrow drainage angle. With age, the lens in the eye becomes larger, pushing the iris forward and narrowing the space between the iris and the cornea. As this angle narrows, the fluid in the eye is blocked from the drainage system. Therefore the fluid builds up and eye pressure increases. Angle-closure glaucoma can be chronic (progressing gradually) or acute (appearing suddenly). The acute form occurs when the iris completely blocks fluid drainage. When people with a narrow drainage angle have their pupils dilated, the angle may close and cause a sudden increase in eye pressure. Although an acute attack often affects only one eye, the other eye may be at risk of an attack as well.

Secondary glaucoma

This type of glaucoma results from an injury or another eye disease. It may be caused by a variety of medical conditions, medications, physical injuries, and eye abnormalities. Infrequently, eye surgery can lead to secondary glaucoma.

Normal-tension or low-tension glaucoma

In this form of glaucoma, eye pressure remains within the “normal” range, but the optic nerve is damaged nevertheless. It is not known why this happens. Possibly, people with low-tension glaucoma have an abnormally sensitive optic nerve. Or they may have a reduced blood supply to the optic nerve caused by a condition such as atherosclerosis, a hardening of the arteries. Under these circumstances, even normal pressure on the optic nerve can cause damage.

The following factors can increase the risk of developing glaucoma:

• Age. People over age 60 are at increased risk for the disease. African Americans, however, are at increased risk after age 40. The risk of developing glaucoma increases slightly with each year of age.
• Race. African Americans are significantly more likely to get glaucoma than Caucasians, and they are much more likely to suffer permanent vision loss. People of Asian descent and Native Alaskans are at higher risk of angle-closure glaucoma. People of Japanese descent are more likely to develop low-tension glaucoma.
• Family history of glaucoma. Having a family history of glaucoma increases the risk of developing glaucoma.
• Medical conditions. Some studies indicate that diabetes, high blood pressure, and heart disease may increase the risk of developing glaucoma.
• Physical injuries to the eye. Severe trauma, such as being hit in the eye, can result in immediate increased eye pressure. Internal damage from such a trauma can also cause future increases in pressure. Injury can also dislocate the lens, closing the drainage angle and increasing pressure.
• Other eye-related risk factors. Certain features of eye anatomy, namely thinner corneas and optic nerve sensitivity, indicate an increased risk for developing glaucoma. Conditions such as retinal detachment, eye tumors, and eye inflammations may also trigger glaucoma. Some studies suggest that high amounts of nearsightedness may also be a risk factor for glaucoma.
• Corticosteroid use. Using corticosteroids (including cortisone, hydrocortisone, and prednisone) for prolonged periods of time appears to put some people at risk of getting secondary glaucoma.

Symptoms

The signs or symptoms of glaucoma can vary depending on the type. Primary open-angle glaucoma often develops slowly and painlessly, with no early warning signs. It can gradually destroy one’s vision without even knowing it. The first indication that a person has glaucoma may occur after some vision has been lost. Acute angle-closure glaucoma results from a sudden blockage of drainage channels in the eye, causing a rapid buildup of pressure. In this form of the disease, a patient would have blurred vision, the appearance of halos or colored rings around lights, and pain and redness in the eye.

Diagnosis

Glaucoma is diagnosed through a comprehensive eye examination. Because glaucoma is a progressive disease, meaning it worsens over time, a change in the appearance of the optic nerve, a loss of nerve tissue, and a corresponding loss of vision confirm the diagnosis. Some optic nerves may resemble nerves with glaucoma, but the patients may have no other risk factors or signs of glaucoma. These patients should have routine comprehensive exams to monitor any changes.

Glaucoma testing includes:

• Patient history to determine any symptoms the patient is experiencing and if there are any general health problems and family history that may be contributing to the problem.
• Visual acuity measurements to determine if vision is being affected.
• Tonometry to measure the pressure inside the eye to detect increased risk factors for glaucoma.
• Pachymetry to measure corneal thickness. People with thinner corneas are at an increased risk of developing glaucoma.
• Visual field testing, also called perimetry, to check if the field of vision has been affected by glaucoma. This test measures your side (peripheral) vision and central vision by either determining the dimmest amount of light that can be detected in various locations of vision, or by determining sensitivity to targets other than light.
• Evaluation of the retina of the eye, which may include photographs or scans of the optic nerve, to monitor any changes over time.
• Supplemental testing, which may include gonioscopy. This procedure offers a view of the angle anatomy, which is where eye fluid drainage occurs. Serial tonometry is another possible test. This procedure acquires several pressure measurements over time, looking for changes in the eye pressure throughout the day. In addition, devices can be used to measure nerve fiber thickness and to look for tissue loss on specific areas of the nerve fiber layer.

Treatment

Glaucoma treatment is aimed at reducing pressure in the eye. Regular use of prescription eye drops are the most common and often the first treatment. Some cases may require systemic medications, laser treatment, or other surgery. While there is not yet a cure for glaucoma, early diagnosis and continuing treatment can preserve eyesight.

Medications

A number of medications are currently available to treat glaucoma. Typically, medications reduce elevated pressure in the eye. A single medication or a combination of medications may be prescribed. The type of medication may change if it is not reducing pressure enough or if the patient is experiencing side effects.

Surgery

Procedures include laser treatment, making a drainage flap in the eye, inserting a drainage valve, or destroying the tissue that creates the fluid in the eye. All procedures aim to reduce the pressure inside the eye when medication is not sufficient. Surgery cannot reverse vision loss.

Laser surgery

Laser trabeculoplasty helps fluid drain out of the eye. A high-energy laser beam stimulates the structure that drains fluid from the eye (the trabecular meshwork) so that fluid drains more efficiently. The results may be somewhat temporary, and the procedure may need to be repeated in the future.

Conventional surgery

If eye drops and laser surgery aren’t controlling eye pressure, the patient may need a trabeculectomy. This filtering microsurgery creates a drainage flap. Fluid can then percolate into the flap and later drain into the vascular system.

Drainage implants

Drainage valve implant surgery may be an option for adults with uncontrolled glaucoma or secondary glaucoma or for children with glaucoma. A small silicone tube is inserted in the eye to help drain fluid.

Treatment for acute angle-closure glaucoma

Acute angle-closure glaucoma is a medical emergency. Those affected can take medication to reduce eye pressure as quickly as possible. They will also likely undergo a laser procedure called laser peripheral iridotomy. In this procedure, a laser beam creates a small hole in the iris to allow fluid to flow more freely into the front chamber of the eye where it then can drain.

Prevention

There is no cure for glaucoma. Patients with glaucoma need to continue treatment for the rest of their lives. Because the disease can progress or change without warning, compliance with eye medications and undergoing eye examinations are essential; treatment may need to be adjusted periodically.

Keeping eye pressure under control can slow or stop damage to the optic nerve and continued loss of vision. Your doctor of optometry may focus on lowering the eye pressure to a level that is least likely to cause further optic nerve damage. This level is often referred to as the target pressure and is likely a range rather than a single number. Target pressure differs for each person, depending on the extent of the damage and other factors. Target pressure may change over time. New medications to help fight glaucoma are always being developed.

Early detection, prompt treatment, and regular monitoring can help to control glaucoma and reduce the chances for vision loss.

Moran CORE | Acute Angle Closure Glaucoma

Acute Angle Closure Glaucoma

Home / Basic Ophthalmology Review / Anterior Chamber

Title: Acute Angle Closure Glaucoma

Author (s): Troy Teeples, 4^th year medical student, University of Utah School of Medicine; Griffin Jardine, MD

Image Designer: Troy Teeples, MSIV University of Utah School of Medicine

Date: 8/7/2018

Keywords/Main Subjects: Acute Angle Closure Glaucoma, painful eye, red eye, pupillary block, halos

Acute Angle Closure Glaucoma

What is it?

Angle-closure glaucoma is a group of diseases in which the angle of the anterior-chamber (the fluid-filled space between the iris and the cornea) closes, which can occur both acutely and chronically. Acute angle-closure glaucoma (AACG) is an ophthalmologic emergency where the intraocular pressure (IOP) rises rapidly due to a sudden blockage of the trabecular meshwork, which normally functions to drain the aqueous humor of the eye. AACG can subsequently be divided into pupillary block versus non-pupillary block.  Pupillary block is where a mid-dilated iris in an already crowded eye makes contact with the lens in a way that impedes aqueous flow through the pupil.  This causes a pressure buildup behind the iris, shifting it anteriorly which further closes the angle and creating a closed fluid system with no outflow, thus rapidly increasing IOP.

Chronic angle closure can cause permanent vision loss over time due to a chronically elevated IOP but typically does not cause pain because of the eye’s ability to adapt to the gradual change in IOP over time.

Patient Presentation

In AACG, patients present with severe eye pain, redness, nausea, vomiting, blurred vision, headache, and may complain of seeing halos around lights. Risk factors for AACG include age (older than 50), being Asian, female or far-sighted (hyperopic). The crisis can be triggered by events that cause pupillary dilation, such as darkened movie theaters, stress or certain medications/drugs. Examination will reveal an elevated IOP, a reddened eye with a steamy cornea (corneal edema) and a moderately dilated pupil that is not reactive to light. Again, a slow, steady rise in IOP over weeks to months—such as in chronic angle closure—is painless and asymptomatic until either detected by a clinician or the patient has substantial and often irreversible optic nerve damage and vision loss.

Treatment

AACG warrants an emergent ophthalmology consult.  Untreated patients can develop permanent vision loss within hours of symptom onset. Initial treatment is targeted to relieve the acute symptoms and reduce the IOP, which is primarily done by drops and oral medicine. Medical therapy works via suppression of aqueous humor production and includes:

• Oral or topical carbonic anhydrase inhibitors (acetazolamide, dorzolamide)
• Topical beta-blockers (timolol)
• Topical alpha-2 adrenergic agonists (brimonidine)

Once the pressure is stabilized, surgical intervention can be employed to reduce the risk of future events, such as a laser peripheral iridotomy (LPI). LPI is the more definitive treatment of primary AACG and should be performed 24-48 hours following resolution of an acute attack in order to prevent future attacks. LPI corrects a pupillary block by using a laser to create an opening in the iris, thereby allowing aqueous fluid to bypass the pupil.

 Image:

This is a diagram of an open angle where the aqueous freely flows around the pupil from the posterior chamber to the anterior chamber and out the trabecular meshwork. On the right is a close angle in pupillary block. This image illustrates several risk factors for AACG, including a thickened lens (which happens with age) and a narrow anterior chamber.  The aqueous is blocked by the iris-lens contact, thus causing pressure to increase in the posterior chamber which pushes the iris forward and closes off the angle or trabecular meshwork.

 References:

Khazaeni B, Khazaeni L. Glaucoma, Acute Closed Angle. [Updated 2017 Apr 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430857/. Accessed 5/18/2018.

Weinreb RN, Aung T., Medeiros FA. The pathophysiology and treatment of glaucoma: a review. JAMA. 2014;311:1901–1911.

Faculty Approval by: Griffin Jardine, MD

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Copyright statement: Copyright Author Name, ©2018. For further information regarding the rights to this collection, please visit: http://morancore.utah.edu/terms-of-use/

Acute angle closure crisis

Take Home Points

• Acute crisis is a true emergency and needs attention immediately

• You or your doctor may have caused the crisis by doing something
  to dilate the pupil

• Symptoms: eye pain (headache), bad vision in one eye or halo vision,
  red eye, pupils of different sizes, nausea

• Immediate treatment is to make a laser iris hole (iridotomy in both eyes)

• Some are cured forever, but others need continued treatment
  after laser iridotomy

• Two special conditions need particular therapy: plateau iris
  syndrome, malignant glaucoma

Acute angle closure crisis deserves its own special mention, as it
is one of the few true emergencies in the glaucoma world. Of all of the
forms of glaucoma, angle closure has a much greater chance to cause
permanent vision loss than open angle glaucoma, and the acute crisis
(frequently called an acute attack) probably accounts for a lot of this
damage. The mechanism by which it happens was described in the preceding
section (Why isn’t glaucoma either there or not there? – What makes you an angle closure suspect?).
It happens to those with angle closure under the situation where aqueous
humor movement from behind to in front of the iris is so blocked that the
pressure behind the iris pushes it against the meshwork and stops all
aqueous outflow (Figure 7). Eye pressure can rise to numbers like 70
millimeters of mercury (compared to the normal 15). This is so high that
permanent damage to ganglion cells in the optic nerve happens in days
to weeks rather than the much longer, slower process of typical glaucoma.

It is the sudden increase in pressure that causes the severe symptoms
of the attack. A link between the stomach and the eye causes an attack to be
not only the worst pain that people ever remember having, but also it causes
nausea and vomiting. 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. Acute attacks also
get misdiagnosed as migraine headaches.

The eye symptoms of acute crisis are pain, poor vision or halo vision
in the involved eye, redness of the white part, and a bigger and irregular
pupil shape. More than 90% of acute crises are in one eye only, but for one
in 10 persons it happens in both eyes. In order to see if an eye problem is in
one eye or the other, one should cover with the hand on one side then the
other. In the excitement of being in pain, we often forget to do such simple
things.

The things that can set off the crisis are those that can cause the pupil
to move to the danger position, half-way dilated. These include stress and
excitement, spending time in a dark place (such as a dimly lit restaurant),
and being exposed to medications that dilate the pupil a bit. This happens
during general anesthesia for surgery, since a drug that dilates the pupil
(atropine) is given by anesthesiologists. If you have bad eye pain after surgery
under general anesthesia, have an exam by an eye doctor immediately. Acute
attacks can also be caused by the many pills that are given that can dilate
the pupil while helping you with things like urinary incontinence, sinus
troubles, and upper respiratory colds. The Food and Drug Administration
doesn’t distinguish the various kinds of glaucoma in its warnings on drugs
about “glaucoma”, so if you are an angle closure suspect who has not had
iridotomy, call your eye doctor before taking any of these drugs. Most of the
time, you’ll hear that it’s fine to take them. After you have an iridotomy,
you can take any of these drugs safely. The final types of drugs that can cause
acute crisis are those used in the eye doctor’s office to dilate the pupil for
examination of the inside of the eye. We’ve seen this a number of times over
the years, and patients who have had dilating drops and have pain the night of
the exam and especially into the next morning should go right back immediately
to be checked. There are a group of medicines that can cause a very unusual form
of acute angle closure in people who otherwise weren’t at risk for it (they
don’t have small eyes or other risk factors for angle closure). One such drug is
topiramate, a headache pill which is also used in epilepsy. Another group of
drugs that can do this are some antibiotics (see section Can the treatments be worse than the disease?).

If you think you are having an acute angle closure crisis, go to the
office of an ophthalmologist (a medical doctor who does surgery and laser
surgery) or to an emergency room that you are sure has an ophthalmologist on
call to come there and see you. Most metropolitan areas have an “eye trauma”
center designated where immediate, appropriate care would be available. Don’t
drive yourself there, get a ride or take a cab.

The immediate treatment for acute crisis will most often fix it in the
first hour. The pressure is lowered by either eyedrops or by letting a small
amount of aqueous out of the eye with a tiny needle. This sounds gruesome,
but you’ll be numbed with eye drops, so you won’t feel it and it immediately
relieves the pain. Sometimes, in order to begin the lowering of pressure, a
laser is used to treat the outer part of the iris to move it away from the
meshwork to let aqueous out faster (laser iridoplasty). The vast majority of
crises are relieved as soon as a hole is placed in the iris with a laser
(Figure 18). This instrument, called a neodymium-YAG
laser, can be focused inside the eye to make the iris hole, without making
any incision or hole in the eye wall (cornea). There is a slight feeling of
pressure and a flick, but typically only eye drop anesthesia is needed.
Several deliveries of the laser may be needed to make a hole about 0. 5
millimeters in diameter. That’s all it takes to relieve most crises.
Occasionally, a second type of laser is used in very thick irises (called a
continuous wave laser or diode) to thin things down before penetrating with
the neodymium-YAG. High quality centers have both available to use. The
opening is usually small enough that others can’t see it from normal social
distances. Those who get within 6 inches of your face for long enough to
find the iris hole are people who know you well enough that they’re
concentrating on other things. Sometimes a small hole is made initially, and
it is made bigger a month later.

The other eye should have a hole made, too, though most persons want
to wait a day or so to try to get back vision in the first eye. Putting it
off for a long time is a really bad idea.

If the crisis has been going on for longer than a day (and you may not
have been aware of it during that time) or if there have been preceding
little attacks in the past that led up to this one, the laser iridotomy
alone is not going to cure everything. There can be scars in the angle that
won’t go away, leading eye pressure to stay high. There may already be damage
to optic nerve structure and visual field function, so that vision is never
fully normal again. Haziness in the lens of the eye (cataract) may be already
present or develop quite quickly after the iridotomy due to the prior high
pressure.

Some have suggested that removing the lens (cataract surgery) would be
a good treatment for acute crisis. Since the reason for the crisis is severe
blockage of fluid movement between the iris and lens, that is a correct
statement, but removing the lens and replacing it with an artificial
intraocular lens by surgery in the middle of an acute crisis is very difficult.
Only the most experienced cataract surgeons, working at a center with
extensive equipment to operate on the retina and vitreous inside the eye
should even attempt this. On occasion, the acute crisis is not broken by laser
iridotomy and by medication—this then calls for forms of glaucoma surgery
(see section Operations for glaucoma).

An uncommon type of glaucoma happens in some eyes that seem to have a
typical acute crisis, but do not respond to standard laser iridotomy, with
pressure remaining high. The doctor will see some special clues that this condition,
called malignant glaucoma has happened. Malignant glaucoma got its name because
it was difficult to deal with; it has nothing to do with cancer. It even happens
sometimes in persons who are not at risk for typical angle closure. 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. The best explanation at present is
that the process starts, like typical angle closure, with choroidal expansion, and
in these folks the vitreous collapses forward due to pressure behind it. The treatments
start with lasers, but then additional types of eye drops, oral and intravenous
medication, and often surgery to make a channel through the vitreous gel are needed to
cure the problem.

Figure 19: Malignant glaucoma. Drawings to illustrate the process that causes malignant
glaucoma. The process starts with expansion of the choroid (shaded
in grey, and thicker than the choroid in the normal eye (see Figure 1)). The higher pressure causes aqueous to
leave the front of the eye, causing a pressure that is higher in the
back of the eye and lower in the front. Normal eyes can make the
pressures equal by having water pass through the vitreous gel that
fills the eye. Eyes with malignant glaucoma have poor water flow
through the vitreous and it collapses forward, carrying the lens and
iris with it until the angle is closed (lower drawing).

Acute Angle Closure Glaucoma

Acute angle closure glaucoma is a rapid or sudden increase in intraocular pressure (IOP), the pressure inside the eye. Acute angle closure glaucoma is an uncommon form of glaucoma, but one that can cause permanent vision loss if you do not seek treatment immediately. Unlike other forms of glaucoma, the symptoms of acute angle closure glaucoma develop suddenly:

Symptoms

• Eye pain and/or headache
• Pain over eyebrow area (can be confused with sinus pain)
• Decreased vision
• Pupils dilated and/or pupils are different sizes
• Red eye
• Nausea and/or vomiting
• Halos or rainbows around lights

If you experience two or more of the symptoms listed above, you should seek treatment at an emergency room immediately. Immediate treatment is necessary to relieve symptoms and prevent loss of vision.

The pain experienced during an acute attack is due to the build-up of a fluid known as aqueous humor within the eye. If the channels within the eye that normally drain the aqueous humor become blocked or otherwise fail to function properly, fluid levels build up, increasing the intraocular pressure within the eye. Although most often acute attacks affect only one eye, occasionally both eyes are affected.

Risks

• Certain populations are at higher risk for an acute angle closure glaucoma attack. They include:
• People of East Asian or Inuit descent who are ages 50 – 80
• People ages 60 – 80
• People who have farsightedness
• People who have previously had symptoms of acute angle closure glaucoma
• People with a close relative (mother, father, sister or brother) who has had acute primary angle closure glaucoma

Treatment

The immediate treatment for acute angle closure glaucoma is to reduce the intraocular pressure as quickly as possible. Several medications can be used to reduce eye pressure, and they are usually delivered via eye drops. Once the intraocular pressure is lowered, laser surgery is used to create a small hole in the iris that allows the aqueous humor to flow freely between the front part of the eye and the area behind the iris. This procedure is called an iridotomy.

Iridotomy is usually advised for the other eye so as to prevent acute angle closure glaucoma from developing (which is otherwise quite likely). Eye drops may also be prescribed to help keep your eye pressure at appropriate levels. 

In general, surgery for acute angle closure glaucoma is successful and long lasting. It is still important to get regular checkups after an episode of acute angle closure glaucoma because a chronic form of glaucoma may still occur.

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90,000 reasons, complaints, diagnostics and treatment methods on the website of the clinic “Alfa-Health Center”

Pathology, characterized by an increase in intraocular pressure, is accompanied by pain and soreness in the eyes, a feeling of heaviness in them, deterioration of twilight vision, and narrowing of the visual fields.

The term “glaucoma” is used to refer to a group of diseases that are characterized by damage (neuropathy) of the optic nerve and changes (loss) of visual fields, usually combined with increased intraocular pressure.Damage to the optic nerve leads to irreversible loss of vision, therefore early diagnosis and timely treatment of glaucoma are very important.

Glaucoma is one of the leading causes of blindness. Late diagnosis is the leading cause of glaucoma blindness.

Intraocular pressure

The main risk factor for glaucoma is increased intraocular pressure. Normal intraocular pressure is 11-21 mm Hg. Art., on average – 15.5 mm Hg. Art. The risk of blindness appears to be directly proportional to the degree and duration of the increase in intraocular pressure.However, up to 20% of patients with characteristic changes in the optic nerve and visual fields have normal intraocular pressure. Other factors, such as vasospasm, appear to contribute to damage to the optic nerve in these patients.

The level of intraocular pressure is influenced by many factors. Intraocular pressure changes during the day and is often higher in the morning. These fluctuations in intraocular pressure depend on individual circadian rhythms and can vary greatly from person to person.Intraocular pressure rises slightly when a person lies on their back.

With arterial hypertension, intraocular pressure increases only slightly, but it can be reduced by prescribing antihypertensive drugs, such as beta-blockers and calcium antagonists. There is no consensus on the effects of caffeine, smoking, and exercise on intraocular pressure. There is also a small group of individuals with hypersensitivity to glucocorticoids. Their intraocular pressure can significantly increase in response to systemic or local (as part of eye drops) use of glucocorticoids.Occasionally, such a reaction is caused by the application of creams or ointments containing glucocorticoids to the skin around the eyes.

Other risk factors

To date, the role of heredity in the development of many types of glaucoma is obvious, and any person with glaucoma in close relatives (parents, brothers and sisters) should be classified as a risk group, especially after 40 years. In addition, the risk of glaucoma increases with diabetes mellitus, high myopia, arterial hypertension, and cardiovascular diseases.

Complaints

Early to moderate primary open-angle glaucoma is often asymptomatic. Only with a pronounced lesion of the optic nerve, patients sometimes notice blurred or blurred vision. On rare occasions, they notice loss of peripheral vision; to detect a visual field defect, it is usually necessary to close the better seeing eye. Patients with intermittent angle-closure glaucoma may complain of eye pain or iridescent circles around light sources.In addition, an attack of angle-closure glaucoma may be accompanied by nausea and vomiting.

Because some symptoms may be mild, absent, or masked by general symptoms, a thorough ophthalmologic examination is important.

Diagnostics

1. Measurement of intraocular pressure. Intraocular pressure is measured by determining the force required to press into the cornea. Most often it is measured with a non-contact air-jet tonometer. The advantages of this method include the absence of the need for anesthesia and the low probability of transmission of infection, since only a stream of air touches the cornea.

2. Study of visual fields. To detect narrowing of the visual fields, special equipment is needed. Ophthalmologists often use automated perimeters, in which the patient is presented with dimmable light sources in standard preset positions of the visual fields.

3. Changes in the optic nerve head. The optic disc can be seen with a direct ophthalmoscope, even without pupil dilation.

Forms of glaucoma

Primary (chronic) open-angle glaucoma is the most common form of glaucoma.At first, the disease is asymptomatic, only in a far advanced stage can the loss of visual fields be detected. Treatment begins with topical medications (eye drops), then, depending on the general condition of the patient and the side effects of the drugs, oral medication, laser surgery or fistulizing surgery may be necessary.

Angle-closure glaucoma usually develops with farsightedness. If left untreated, an acute attack of glaucoma can lead to blindness due to severe damage to the optic nerve.The primary task of treatment is to reduce intraocular pressure as quickly as possible; in this situation, an immediate visit to an ophthalmologist is required.

Treatment

With all the variety of glaucoma, only a few methods of reducing intraocular pressure are known. They are used consistently as the disease worsens.

Start with the use of eye drops that reduce intraocular pressure. These drugs inhibit the production or increase the outflow of aqueous humor.Sometimes a combination of several drugs is used. Often prescribed beta-blockers can have side effects on the cardiovascular system and bronchi.

When drugs stop reducing intraocular pressure, they resort to trabeculoplasty using an argon laser. The intervention is performed on an outpatient basis. For the first time, it gives an effect in almost 80% of patients. Unfortunately, after 5 years in about half of successfully treated patients, intraocular pressure rises again.

Operations that create pathways for the outflow of aqueous humor from the anterior chamber of the eye under the conjunctiva effectively reduce intraocular pressure. The operation is successful in 85-90% of cases, but sometimes it causes severe complications, including the formation of cataracts. Surgical treatment allows you to reduce the dose of drugs or cancel them. In addition, the effectiveness of such treatment does not depend on how conscientiously the patient follows the doctor’s prescriptions. Surgical treatment is most often carried out when drug and laser treatment is unsuccessful.

Glaucoma | Health in Omsk

Glaucoma is an increase in intraocular pressure due to excess intraocular fluid.

Normally, nutrition of the internal structures of the eye is provided by constant circulation of fluid – the so-called “aqueous humor”. This fluid performs the function of removing waste metabolic products through a small space between the edge of the iris and the lens, and then through the openings of the iris-corneal angle outward.The pathological condition is caused either by an excess of the formation of intraocular fluid, or by a violation of its outflow – then glaucoma develops.

Forms of glaucoma

Depending on the reasons for the development of glaucoma, the course of the disease will also differ, and therefore the symptoms of glaucoma.

• Open-angle form is the most common case of glaucoma. With this flow, the iris-corneal angle, responsible for the outflow of fluid, remains open – hence the name.All the reasons for the development of acute-angle glaucoma have not yet been identified, but the course of the disease has been described in sufficient detail.

  The open-angle form of glaucoma is characterized by a chronic course. The fluid accumulates gradually, often over several years, and therefore the patient may simply not notice an increase in intraocular pressure to a certain level. With the development of the disease, vision problems arise – a decrease in the angle of visibility (peripheral vision), sometimes clouding and the formation of persistent defects in the visual field – if the optic nerve is damaged.In the advanced and terminal stages, the symptoms are similar to the closed-angle form – soreness of the eye, severe visual impairment, headaches, often radiating to the back of the head.

• The closed-angle shape of , as the name suggests, is due to the overlap of the iris-corneal angle and the inability to drain the waste fluid. This is a rare form (in relation to open-angle glaucoma – 1:10). For angle-closure glaucoma, a paroxysmal course is characteristic – the pressure rises sharply and strongly, which is very noticeable – there is pain, blurred vision, redness of the eye.The eyeball is firm to the touch.

If you suspect glaucoma, it is necessary to consult a specialist – both acute attacks and chronic imperceptible deterioration of the functions of the eye are dangerous. It is important to differentiate symptoms, for example, with migraines or hypertension – and this can often only be done by a doctor.

Causes of glaucoma

If the main course of development of glaucoma is more or less clear – the pressure rises either due to the impossibility of outflow or excess fluid production – then the causes of disturbances in the mechanisms of circulation of aqueous humor are not fully understood.Among the reasons identified are called:

• Disorders in intrauterine development – congenital defects of the eye;
  Disorders of the muscles and blood vessels of the eye, for example, with myopia;
• Oncological diseases, including benign ones – various formations that block the outflow of fluid;
• External factors – eye injuries, surgery;
• Lens disorders – for example, hyperopia or cataracts;
• Some common diseases are diabetes mellitus, hypertension.

Most of these conditions can provoke both open-angle and closed-angle glaucoma. An acute attack of a closed-angle form also often occurs due to the patient’s own actions – for example, improper use of drops that dilate the pupil, as well as prolonged stay in dimly lit spaces.

Glaucoma treatment

Today glaucoma is an incurable, steadily progressive disease.

The goal of therapy in chronic open-angle glaucoma is to slow down the process of damage to the tissues of the eye and optic nerve, for which intraocular pressure is reduced by drugs (drops, tablets) or by surgical methods (creating new outflow pathways).

Treatment in the acute phase – during a closed-angle attack – requires immediate specialist intervention. A sharp jump in pressure can cause irreversible blindness – therefore, it is necessary to remove excess fluid, to prevent damage to the nerve.

The goal of angle-closure glaucoma treatment is to alleviate the general condition of the patient, which is often accompanied by headache, weakness and other symptoms.

Why is glaucoma dangerous?

The result of the development of glaucoma in any form is irreversible loss of vision. Lack of nutrition and a constant increase in pressure has a destructive effect both on the internal structures of the eye – the retina, the lens – and on the optic nerve, causing its atrophy.Only a timely visit to a doctor can postpone blindness, which is not always possible in the latent phase.

Assessment of the severity of vision loss – Differential diagnosis of symptoms

Many patients in primary care are often out of reach of timely surgical care. [1] Rossi T, Boccassini B, Iossa M, et al. Triaging and coding ophthalmic emergency: the Rome Eye Scoring System for Urgency and Emergency (RESCUE): a pilot study of 1,000 eye-dedicated emergency room patients.Eur J Ophthalmol. 2007 May-Jun; 17 (3): 413-7.
http://www.ncbi.nlm.nih.gov/pubmed/17534826?tool=bestpractice.com
[2] Fea A, Bosone A, Rolle T, et al. Eye injuries in an Italian urban population: report of 10,620 cases admitted to an eye emergency department in Torino. Graefes Arch Clin Exp Ophthalmol. 2008 Feb; 246 (2): 175-9.
http://www.ncbi.nlm.nih.gov/pubmed/18183412?tool=bestpractice.com

Loss of vision can occur as a result of a violation of the visual apparatus – from the lacrimal film to the occipital cortex.The most important factor for initial diagnosis is the rate of onset of symptoms. It is also important to assess early for the presence of associated symptoms such as pain, diplopia, flashes and / or flies. This helps to identify patients with a potentially life-threatening illness and to highlight those patients requiring ophthalmologic consultation or immediate surgery. [1] Rossi T, Boccassini B, Iossa M, et al. Triaging and coding ophthalmic emergency: the Rome Eye Scoring System for Urgency and Emergency (RESCUE): a pilot study of 1,000 eye-dedicated emergency room patients.Eur J Ophthalmol. 2007 May-Jun; 17 (3): 413-7.
http://www.ncbi.nlm.nih.gov/pubmed/17534826?tool=bestpractice.com
[3] Ramos M, Kruger EF, Lashkari K. Biostatistical analysis of pseudophakic and aphakic retinal detachments. Semin Ophthalmol. 2002 Sep-Dec; 17 (3-4): 206-13.
http://www.ncbi.nlm.nih.gov/pubmed/12759852?tool=bestpractice.com

In case of acute vision loss that occurs suddenly or within a few minutes or hours, an urgent consultation with an ophthalmologist is required.In subacute or chronic cases (when vision has deteriorated over weeks, months, or years), specialist advice may be needed, but usually not urgent.

Any significant loss of vision justifies contacting an ophthalmologist for a consultation within a certain time frame.

Loss of vision can also be the initial manifestation of a number of systemic diseases for which a separate clinical investigation is required. [4] Klig JE. Ophthalmologic complications of systemic disease.Emerg Med Clin North Am. 2008 Feb; 26 (1): 217-31.
http://www.ncbi.nlm.nih.gov/pubmed/18249264?tool=bestpractice.com

Acute loss of vision

Retinal or optic nerve disease is usually acute. Other acute causes of vision loss include acute-angle closed glaucoma, retinal vascular occlusion, and trauma.

Patient age and medical history help in diagnosis.

Chronic vision loss

Patients may recognize symptoms of chronic worsening “acutely”, which means chronic vision loss can occur in the emergency department, making diagnosis difficult.

The analysis of associated symptoms makes it possible to distinguish between urgent and non-urgent cases and to organize appropriate ophthalmological consultations.

Systemic guidelines

It is essential to take a thorough medical history, focusing on vascular, neurological and vision problems.

Diabetic retinopathies can develop prior to the diagnosis of systemic diabetes, making it important to measure blood glucose levels in all patients with acute visual loss.Arrange eye examinations for all newly diagnosed adults with diabetes. [5] Jones HL, Walker EA, Schechter CB, et al. Vision is precious: a successful behavioral intervention to increase the rate of screening for diabetic retinopathy for inner-city adults. Diabetes Educ. 2010 Jan-Feb; 36 (1): 118-26.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4582664/

http://www.ncbi.nlm.nih.gov/pubmed/20044537?tool=bestpractice.com
[6] Solomon SD, Chew E, Duh EJ, et al.Diabetic retinopathy: a position statement by the American Diabetes Association. Diabetes Care. 2017 Mar; 40 (3): 412-8.
https://www.doi.org/10.2337/dc16-2641

http://www.ncbi.nlm.nih.gov/pubmed/28223445?tool=bestpractice.com

For other severe systemic diseases (including granulomatosis with polyangiitis, bacterial meningitis, or disseminated malignant tumors), an emergency department visit or hospitalization is possible. [7] Mitra A, Chavan R, Gunda M.Occult giant cell arteritis and steroid therapy: how urgent is urgent? Ann Ophthalmol (Skokie). 2006 Winter; 38 (4): 343-5.
http://www.ncbi.nlm.nih.gov/pubmed/17726223?tool=bestpractice.com

Preparations for the treatment of glaucoma | Medicinal Directory | Health

Save the apple of your eye | Remedium.ru

Many serious illnesses must be closely monitored by the attending physician. We, pharmacy specialists, although we cannot prescribe drugs for their treatment (especially prescription drugs) ourselves, must be “in the know” and have a good understanding of the symptoms and pharmacological groups.



Pressurized

Take glaucoma, for example. This serious eye disease is expressed in an increase in intraocular pressure (IOP), which can subsequently lead to retinal degeneration and complete blindness.

The disease can appear at any age, starting from birth, but is more common in older people.

Glaucoma is a multifactorial disease with a threshold effect. This means that the development of symptoms depends on a number of causes and risk factors, which together trigger the pathological process. This is mainly influenced by heredity, individual features of the structure of the eye, pathology of the cardiovascular, nervous and endocrine systems (diabetes mellitus, arterial hypotension and hypertension, atherosclerosis, cervical osteochondrosis, etc.). As a result, the outflow of moisture from the cavity of the eyeball is disturbed, IOP increases, and blood circulation in the tissues of the eye worsens. In this case, the visual fibers in the zone of their exit from the eyeball are compressed and atrophied, which leads to their death and, as a result, to blindness.

Variety of shapes and types

Distinguish between congenital, adolescent, primary and secondary glaucoma, but the primary, especially its open-angle form, is of the greatest interest.It occurs in over 90% of all cases and usually affects both eyes. The iris-corneal angle is open and the outflow of intraocular fluid is disturbed, which leads to its accumulation and a constant increase in IOP and, as a result, to the destruction of the optic nerve. An important sign of open-angle glaucoma is a change in the visual field.

The insidiousness of acute-angle glaucoma is that it occurs and progresses imperceptibly for a person, and visual impairment is observed already at a late stage of the disease.

Drop by drop

Nerve damage and vision loss in glaucoma cannot be repaired. If visual functions are already impaired due to an illness, then it will not be possible to return everything to its original state. However, modern means will help slow down or stop the progression of the disease.

Treatment of glaucoma consists in normalizing the IOP level and includes, first of all, pharmacotherapy, laser methods and microsurgery.

What drugs are used for this purpose? These are drugs of different groups. Prostaglandins, for example, Travatan, reduce IOP by improving the outflow of intraocular fluid, and beta-blockers by inhibiting its production. At the same time, for the treatment of glaucoma, both non-selective (containing timolol – Arutimol, Okumed, Okumol, etc.) and selective beta-1-blockers (eye drops based on betaxolol – Betoptic and Betoptic C) are used.



Original or copy?

Pharmacy shelves are full of generics.And even experienced pharmacists sometimes wonder why the original drug is better than copies? The composition and properties are the same, but it costs more. Nevertheless, there is a difference, and you, as a pharmaceutical specialist, must understand it and be able to explain it to your customers.

Original drugs were synthesized for the first time, and their properties are being studied in numerous clinical studies. The chemical formula of the active substance has been protected by a patent for many years, so the company receives the exclusive right to manufacture and sell the drug.

Indeed, the original is more expensive than any of the many generics. This is due to the fact that the development of a new drug is a laborious, long-term and expensive process. The price includes the costs of development and clinical trials, training of doctors and pharmaceutical specialists, promotion and marketing costs.

Generics, in contrast to the originals, although they contain the same active ingredient, are reproduced and not researched, therefore the effectiveness of the copies is often lower than that of the “pioneer”.

Considering this, it is better to choose original drugs. For example, Betoptic or Betoptic C , manufactured by Alcon , the largest manufacturer of ophthalmic drugs. When using these eye drops, the hypotensive effect is observed 30 minutes after instillation and lasts for 12 hours. Compared to other beta-blockers, Betoptic does not cause a decrease in blood flow in the optic nerve, and, unlike miotics, does not lead to the appearance of miosis, accommodation spasm and the “veil” effect in front of the eyes.

Warn the visitor!

– the effect of drugs may not appear immediately, but after a few days, gradually increasing under the condition of regular instillation of eye drops

– when instilling antiglaucoma drugs, it is necessary to be observed by a doctor for 2-3 weeks, and then visit an ophthalmologist at least once every 3 months

– it is impossible to independently cancel or change the frequency of use of antiglaucoma drugs.

Mila Martynova, pharmacist

Acute-angle glaucoma: symptoms, treatment, prevention

Narrow-angle glaucoma is common among ophthalmic diseases. This is a chronic type of disease in which the quality of vision deteriorates due to the abnormal structure of the anterior chamber of the optic organ. Close-angle and acute-angle glaucoma are considered to be close in pathogenesis. The risk group includes the elderly and patients with chronic ophthalmic diseases.For diagnosis, the doctor prescribes a number of instrumental procedures. The advantage of this disease is the fact that it can be completely cured. For this, medications or surgical methods are used.

Acute-angle glaucoma occurs quite often, almost 10% of patients from the total number of patients with this ailment deal with this type.

Etiology

The main factor that can provoke an ailment lies in the anatomical features of the optic organ.The anterior chamber is located between the cornea and the iris with the lens. With age, some changes occur in the structure of these organs, namely, an increase in the lens and movement of the iris occur. If the anterior chamber is narrow, it gets even smaller over time. This process causes blockage of the channels and no drainage occurs.

Intraocular pressure affects the condition of the eye. It rises against the background of a general increase in blood pressure indicators. Therefore, the chronic form of hypertension is also a provoking factor.The acute-angled type of the disease, like other types, has a genetic nature of development. Doctors pay attention to this first of all when they determine the cause of the process. In addition, a number of factors are distinguished that can transfer the disease from the chronic stage to the exacerbation phase. These include:

Under stress, a person’s illness may worsen.

• stress;
• use of means for pupil dilation;
• long-term antidepressant treatment;
• alcoholism;
• mechanical damage to the head and directly to the eyes;
• overload of the visual organs of a regular nature;
• severe hypothermia stage.

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Risk group

Glaucoma can develop at any age, but more often the disease is diagnosed after 60 years. The development of the disease at an earlier age signals the presence of other pathological processes that require urgent treatment. Ophthalmologists identify a number of factors that are provoking. Thus, the following categories of people fall into the risk group:

• women over the age of 45; 90,068 90,061 people of the Asian race; 90,068 90,061 patients with hyperopia;
• patients with pathologies of the circulatory system;
• patients with dystrophic structure of the chambers of the optic organ.

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Possible symptoms

With this pathology, a person’s headache can be paroxysmal.

The first stages of the process are asymptomatic. According to clinical indications, visual acuity decreases, but this happens slowly, and the patient is not always able to notice changes immediately. The initial stage is called cornerstone glaucoma. At this stage, it is worth contacting a doctor, the chances of a full recovery in this case are maximum. The active stage of the disease can be recognized by the following symptoms:

• the appearance of a veil before the eyes;
• decrease in visual qualities;
• glare and flares in front of the eyes;
• painful sensations in the eyes;
• nausea;
• paroxysmal headache;
• Painful sensations in the forehead and under the eyes;
• swelling of the visual organs;
• redness of the eyes;
• increased lacrimation.

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Diagnostics

The patient should be carefully examined using electronic tomography.

The ophthalmologist must examine the eye with a slit lamp for confirmation, examine the condition of the iris of the lens and the optic nerve head. Glaucoma is confirmed if there is a triangular anterior chamber configuration. The complete picture for the appointment of a therapeutic method can be established only after the tests carried out. The list of required diagnostic procedures includes the following methods:

• Tonometry – measurement of intraocular pressure indicators.
• Perimetry – examination of visual fields.
• Gonioscopy – examination and measurement of the camera angle.
• Electron tomography – obtaining data on the hydrodynamics of the eye.

In the process of diagnostics, the state of the optic nerve is studied. For this, MRI, CT and radiography are additionally prescribed.

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Treatment of ailment

Selection of the correct therapeutic method makes it possible to completely eliminate defects and restore normal vision.Treatment depends on the stage of development of the disease, the ophthalmologist himself determines what needs to be done in a particular case. If you leave the process without intervention, there is a high probability of complete loss of vision. There are 2 effective methods of treatment:

Fotil will help the patient if the pathology is diagnosed at the initial stage of development.

• Conservative. Prescribed drug therapy in the early stages of the development of the disease. Miotics and inhibitors in the form of drops are used to reduce intraocular pressure and improve metabolic processes.Popular drugs for glaucoma: “Nomoglaucon”, “Fotil”. Ophthalmic agents can be addictive, so the course is constantly adjusted by the doctor.
• Surgery. The classical and laser method is used, the second is more popular and safe, but expensive. With the help of the beam, defects are removed without contact, and the patient’s eyesight is restored.

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Prevention

Acute-angle glaucoma can develop at any age, it is often considered an uncontrollable ailment.Therefore, there are no precise preventive measures. However, ophthalmologists recommend monitoring the level of blood pressure, pay attention to physical fitness and nutrition. In addition, it is important to protect the eyes from damage of all levels. It is worth wearing sunglasses. The main aspect of prevention is the timely treatment of ophthalmic diseases, which can develop into more dangerous conditions.

Glaucoma – Symptoms and Causes

It is important to have a comprehensive eye exam every year./ Photo kp.ru

Glaucoma is an eye disease that can damage the optic nerve, which is responsible for transmitting visual information to the brain.

Contents

Glaucoma, unlike cataracts, is usually, but not always, the result of abnormally high pressure in your eye. Over time, the increased pressure can destroy the optic nerve tissue, which can lead to loss of vision or even blindness. If the disease is diagnosed early, vision loss can be prevented.

The most common type of glaucoma is primary open-angle glaucoma. She has no signs or symptoms other than a gradual loss of vision. For this reason, it is important that you have comprehensive eye examinations every year so that your ophthalmologist or eye specialist can monitor any changes in vision.

Closed acute-angle glaucoma, also known as narrow-angle glaucoma, is a medical emergency. See your doctor right away if you experience any of the following symptoms:

• severe eye pain
• nausea
• vomiting
• redness in the eyes
• sudden visual disturbances
• colored rings around lights
• sudden blurred vision

The back of your eye constantly creates a clear liquid that fills the front of your eye.It then leaves your eye through channels in the cornea and iris. If these channels are blocked or partially closed, the natural pressure in your eye, called intraocular pressure (IOP), may increase. With an increase in IOP, the optic nerve can be damaged. As the nerve is damaged, you may begin to lose your eyesight.

What causes the pressure in your eye to rise is not always known. However, doctors believe that one or more of these factors may play a role:

• dilating eye drops
• blocked or limited drainage in the eye
• drugs such as corticosteroids
• poor or reduced blood flow to the optic nerve
• high or high blood pressure

There are five main types of glaucoma.Among them:

Open-angle (chronic) glaucoma

Open-angle or chronic glaucoma has no signs or symptoms other than a gradual loss of vision. This loss can be so slow that irreparable damage can be done to your vision before any other signs appear. According to the National Eye Institute (NEI), this is the most common type of glaucoma.

Angle-closure glaucoma

If fluid flow is suddenly blocked, rapid buildup can cause severe, rapid, and painful pressure build-up.Angle-closure glaucoma is an emergency. You should call your doctor immediately if you develop symptoms such as severe pain, nausea, and blurred vision.

Congenital glaucoma

Babies born with congenital glaucoma have a defect in the corner of the eye that slows down or prevents the normal drainage of fluid. Congenital glaucoma is usually accompanied by symptoms such as cloudy eyes, excessive watery eyes, or sensitivity to light.

Secondary glaucoma

Secondary glaucoma is often a side effect of trauma or other eye disease, such as cataracts or eye swellings. Medications such as corticosteroids can also cause this type of glaucoma. Rarely, eye surgery can cause secondary glaucoma.

Normal Stress Glaucoma

In some cases, people without increased eye pressure develop optic nerve pathology. The reason for this is unknown.However, extreme sensitivity or lack of blood flow to the optic nerve can be the cause of this type of glaucoma.

According to a reliable source from the World Health Organization (WHO), glaucoma is the second leading cause of blindness worldwide. Risk factors for glaucoma include:

Age

People over 60 are at increased risk of glaucoma, warns NEI, and the risk of glaucoma increases slightly every year.

Ethnicity

African Americans or people of African descent are significantly more likely to develop glaucoma than Caucasians. People of Asian descent are at a higher risk of angle-closure glaucoma, and people of Japanese descent have a higher risk of developing low-voltage glaucoma.

Eye problems

Chronic inflammation of the eyes and thin corneas can lead to increased pressure in the eyes. Physical injury or trauma to the eye, such as a blow to the eye, can also lead to increased eye pressure.

Medical history

People with diabetes and people with high blood pressure and heart disease have an increased risk of developing glaucoma.