Signs and symptoms of acute angle closure glaucoma: Glaucoma – Symptoms and causes
Acute Angle Closure Glaucoma: Causes, Symptoms, Treatment
This serious condition makes the pressure inside your eye (your doctor may call it intraocular pressure, or IOP) go up suddenly. It can rise within a matter of hours. It happens when fluid in your eye can’t drain the way it should. It isn’t as common as other types of glaucoma, which cause pressure buildup much more slowly over time.Acute angle-closure glaucoma is caused by a rapid or sudden increase in pressure inside the eye, called intraocular pressure (IOP).
Fluid drains out of your eye through a system of canals. These canals live in a mesh of tissue between your iris (the colored part of your eye) and your cornea (the clear outer layer).
When your iris and cornea move closer together, it “closes the angle” between them. When this happens suddenly, it’s called an acute attack and is very painful.
Acute angle closure glaucoma completely blocks your canals. It stops fluid from flowing through them, kind of like a piece of paper sliding over a sink drain. The pressure that builds up can damage your optic nerve. If you don’t treat the problem quickly enough, you could lose your sight completely.
You might have an attack of angle closure glaucoma if you have narrow drainage systems and your eyes dilate (your pupil gets bigger) too much or too quickly. This can normally happen when you:
Some health conditions can also cause angle closure glaucoma:
Women are 2 to 4 times more likely to get it than men. You’re also more likely to have it if you’re:
Or if you:
- Have a family history of it
- Use medications that dilate your pupils
- Use other medications that cause your iris and cornea to come together, like sulfonamides, topiramate, or phenothiazines
If you have acute angle closure glaucoma in one eye, you’re also more likely to get it in the other.
They come on quickly. You won’t be able to ignore them. They include:
- Eye pain
- Severe headache
- Nausea or vomiting
- Very blurry or hazy vision
- Seeing rainbows or halos around lights
- Redness in the white part of the affected eye
- Pupils of different sizes
- Sudden loss of sight
When your doctor examines you, they may also notice that your pupils no longer get smaller or bigger when they shine light on them.
If you think you have acute angle closure glaucoma, you’ll need to see an ophthalmologist right away — it’s an emergency. They’ll examine you and ask about your symptoms. They may do one or more tests to find out more about what’s going on inside your eye:
- Gonioscopy: The doctor uses a lens with a simple microscope called a slit lamp to look into your eye. A beam of light checks the angle between your iris and cornea and see how well fluid drains.
- Tonometry: This test uses a tool to measure the pressure inside your eye.
- Ophthalmoscopy: Your doctor checks for damage to your optic nerve with a small lighted device.
The first thing your doctor will do to treat your acute angle closure attack is try to get rid of some of the pressure in your eye. They might use:
- Drops that narrow your pupil
- Medication to lowers the amount of fluid your eye makes
Once your IOP has dropped a little, your doctor may use a laser to:
- Make a small hole in your iris. This is called a laser iridotomy, and it helps the fluid start flowing again inside your eye. It’s an outpatient treatment, and takes a few minutes.
- Pull the edges of your iris away from your drainage canals. This called laser iridoplasty or gonioplasty.
If you have cataracts, your doctor may consider surgery to replace the lens in your eye. This type of surgery can be harder to do when you’re having an acute attack.
Even if your acute angle closure glaucoma is in only one eye, your doctor will probably treat both eyes, just to be safe.
The best way to prevent an acute angle closure glaucoma attack is to get your eyes checked regularly, especially if you’re at high risk. Your doctor can keep tabs on pressure levels and how well fluid drains. If they think your risk is unusually high, they may suggest laser treatment to hold off an attack.
What are the signs and symptoms of acute angle-closure glaucoma (AACG)?
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.
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.
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.
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.
Angle-Closure Glaucoma – Eye Disorders
Narrow angles are not present in young people. As people age, the lens of the eye continues to grow. In some but not all people, this growth pushes the iris forward, narrowing the angle. Risk factors for developing narrow angles include family history, advanced age, and ethnicity; risk is higher among people of Asian and Inuit ethnicity and lower among people of European and African ethnicities.
In people with narrow angles, the distance between the iris at the pupil and the lens is also very narrow. When the iris dilates, forces pull the iris centripetally and posteriorly causing increasing iris–lens contact, which prevents aqueous from passing between the lens and iris, through the pupil, and into the anterior chamber (this mechanism is termed pupillary block). Pressure from the continued secretion of aqueous into the posterior chamber by the ciliary body pushes the peripheral iris anteriorly (causing a forward-bowing iris called iris bombe), closing the angle. This closure blocks aqueous outflow, resulting in rapid (within hours) and severe (> 40 mm Hg) elevation of intraocular pressure (IOP).
Because of the rapid onset, this condition is called primary acute angle-closure glaucoma and is an ophthalmic emergency requiring immediate treatment. Non-pupillary block mechanisms include plateau iris syndrome in which the central anterior chamber is deep, but the peripheral anterior chamber is made shallow by a ciliary body that is displaced forward.
Intermittent angle-closure glaucoma occurs if the episode of pupillary block resolves spontaneously after several hours, usually after sleeping supine.
Chronic angle-closure glaucoma occurs if the angle narrows slowly, allowing scarring between the peripheral iris and trabecular meshwork; IOP elevation is slow.
Pupillary dilation (mydriasis) can push the iris into the angle and precipitate acute angle-closure glaucoma in any person with narrow angles. This development is of particular concern when applying topical agents to dilate the eye for examination (eg, cyclopentolate, phenylephrine) or for treatment (eg, homatropine) or when giving systemic drugs that have the potential to dilate the pupils (eg, scopolamine, alpha-adrenergic agonists commonly used to treat urinary incontinence, drugs with anticholinergic effects).
Acute Closed Angle Glaucoma – StatPearls
Continuing Education Activity
Acute angle-closure glaucoma is an ocular emergency that results from a rapid increase in intraocular pressure due to outflow obstruction of aqueous humor. Several factors lead 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 between the iris and the cornea. 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. The physical exam will reveal a fixed midpoint pupil and a hazy or cloudy cornea with marked conjunctival injection. This activity reviews the evaluation and management of patients with acute angle-closure glaucoma and highlights the role of the interprofessional team in managing patients with this condition.
Describe the pathophysiology of acute angle-closure glaucoma.
Summarize how a patient with acute angle-closure glaucoma is likely to present.
Identify the critical immediate steps to take when managing a patient with acute angle-closure glaucoma.
Outline the role of a collaborative interprofessional team in providing well-coordinated care to patients presenting with acute angle-closure glaucoma.
Access free multiple choice questions on this topic.
Glaucoma is a set of ocular disorders often defined by increased intraocular pressures leading to optic neuropathy and vision loss if untreated. 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 to 22 mmHg. Three factors that affect the intraocular pressure are 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. Several factors lead 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.
Blockage to the flow of 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 difference between the chambers called a pupillary block. 
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.
There are several risk factors for acute angle-closure glaucoma, including age, gender, race, and family history.
Age: The 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 to 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.
Family history: Ocular anatomic features are inherited.
An acute attack of angle-closure glaucoma is precipitated by pupillary dilatation, leading to increasing iris and lens contact increasing the pupillary block.  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 tract. 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. 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 cells may be seen. The optic nerve may also be swollen during an acute attack.
Measuring elevated intraocular pressure is diagnostic. There is no need for any imaging studies. A basic metabolic panel should be checked if osmotic agents are used in the treatment regime. 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.
Initial medical therapy includes a combination of the following medications:
Intravenous acetazolamide 500 mg to block the production of aqueous humor.
Intravenous mannitol 1 to 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% to 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.
Definitive treatment is peripheral iridectomy after the acute episode subsides. Laser iridectomy is the treatment of choice. Surgical iridectomy is indicated when laser iridectomy 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. 
Bacterial conjunctivitis (pink eye)
Senile cataract (age-related cataract)
The prognosis depends on early detection and prompt treatment of acute closed-angle glaucoma. A study conducted on 116 cases of acute angle-closure glaucoma concluded that the delay in presentation and the time taken to end the acute episode was the most important factor in determining the final outcome of these patients. High intraocular pressure was less effective in determining the long-term prognosis of this condition.
If acute closed-angle glaucoma is not detected and treated in its initial stages, it can lead to temporary loss of vision or blindness. There is a loss of peripheral vision, followed by a loss of central vision. There can be a significant increase in IOP in patients with peripheral patent iridotomy and a flat anterior chamber. This condition is called malignant glaucoma. This condition is difficult to treat and progressively leads to blindness.
Deterrence and Patient Education
Patients with a history of acute angle-closure glaucoma should avoid dim light. Pupils dilate in response to dim light, further narrowing the iridocorneal angle. Patients with hypermetropia are at an increased risk of developing angle-closure glaucoma.
Pearls and Other Issues
An untreated opposite eye has a 40% to 80% chance of developing an acute attack of angle-closure glaucoma over 5 to 10 years as it shares the same anatomic predisposing factors as the first eye. Hence peripheral iridectomy should be performed in the other 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. Studies have been conducted on possible therapeutic targets in patients with early-onset glaucoma based on molecular and cellular events caused by MYOC, OPTN, and TBK1 mutations.
Enhancing Healthcare Team Outcomes
Acute angle-closure glaucoma is best managed by an interprofessional team, including an ophthalmologist, family clinician, an ophthalmology nurse, and the pharmacist. After managing the emergency with eye drops, the patient should be scheduled for an iridectomy. Clinicians need to be aware that the other eye is also at risk for acute angle-closure glaucoma, and prophylactic surgery is recommended.
The outcomes for patients with acute angle-closure glaucoma are good following treatment. However, delay in treatment can lead to damage to the optic nerve and vision loss.
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Acute angle closure glaucoma – A potential blind spot in critical care
J Intensive Care Soc. 2017 Aug; 18(3): 244–246.
Milton Keynes University Hospital, NHS Foundation Trust, Milton Keynes, UK
Corresponding author.Anna Petsas, Anaesthetics Department, Milton Keynes University Hospital NHS Foundation Trust, Standing Way, Eaglestone, Milton Keynes MK6 5LD, UK. Email: [email protected] article has been cited by other articles in PMC.
We report a case of a 69-year-old gentleman who developed an acutely painful eye with loss of visual acuity whilst on the critical care unit. He was admitted three days previously with an infective exacerbation of chronic obstructive pulmonary disease requiring invasive mechanical ventilation. In addition, he received intravenous antibiotics, steroids, nebulised bronchodilators and intravenous aminophylline, together with noradrenaline for blood pressure support. On development of visual symptoms, an emergency ophthalmology review diagnosed acute angle closure glaucoma. Treatment with pilocarpine eye drops, intravenous acetazolamide and bilateral YAG laser iridotomies provided immediate symptom relief and he went on to make an excellent recovery. Acute angle closure glaucoma is a potentially devastating ophthalmic emergency. Critical care patients are at particular risk for the development of this condition due to the use of predisposing medications, such as sympathomimetics and beta agonists. Sedated patients also run a risk of delayed diagnosis so a high index of suspicion is required.
Keywords: Acute angle closure glaucoma, ophthalmic emergency, visual loss, painful eye
Acute angle closure glaucoma (AACG) is an ophthalmic emergency that progresses to blindness if untreated. Raised intraocular pressure (IOP) resulting in damage to the optic nerve occurs secondary to obstruction of the drainage of aqueous humour from narrowing or closure of the anterior chamber angle. Critically ill patients are at particular risk of developing this sight-threatening condition due to premorbid comorbidities, the development of critical illness and its pharmacological management along with challenging diagnostic circumstances associated with low conscious states.
A 69-year-old gentleman presented via the emergency department (ED) in type 2 respiratory failure with a four-day history of cough and increasing shortness of breath. He presented in extremis with tachycardia, hypotension, hypoxia and hypercapnia and had a mixed respiratory and metabolic acidosis. His medical history includes chronic obstructive pulmonary disease (COPD) and peripheral vascular disease.
He was intubated in the ED and transferred to the intensive care unit (ICU) where he was treated for a community-acquired pneumonia, exacerbation of COPD and septic shock. His treatment included intravenous pipercillin/tazobactam, aminophylline and steroids, nebulised salbutamol and ipratropium bromide and cardiovascular support with noradrenaline. His ventilation improved, and within 24 h, he was extubated and aminophylline and noradrenaline were weaned. He remained on nebulised bronchodilators for a further day.
On the evening of day three of admission, he developed right-sided eye pain, redness and decreased visual acuity. This worsened throughout the course of the night and by the morning began to also affect his left eye. He was seen urgently in the onsite ophthalmology clinic the same morning. On examination, his visual acuity was assessed as counting fingers in the right eye and 6/18 in the left. His right eye had a fixed and dilated pupil, with a shallow anterior chamber and a hazy cornea. The IOPs were 45 mmHg and 20 mmHg in the right and left eyes, respectively. A diagnosis of AACG of the right eye was made, and the left eye was also considered to be at risk of AACG with a markedly narrow angle. Immediate treatment was commenced with pilocarpine eye drops, intravenous acetazolamide and bilateral YAG laser peripheral iridotomies. This decreased the IOPs to 22 mmHg in the right eye and 16 mmHg in the left eye with immediate symptomatic relief.
Clinically, he continued to improve both from his ophthalmic and respiratory conditions and was discharged to the ward following a seven-day ICU stay and subsequently home.
AACG is an ophthalmic emergency and, if left untreated, can lead to blindness. It is defined as the appositional or synechial closure of the anterior chamber angle.1 The narrowing or closure of the anterior chamber angle blocks the drainage of aqueous humour, resulting in elevated IOP and damage to the optic nerve.
Aqueous humour is produced by the ciliary body in the posterior chamber of the eye and diffuses from the posterior chamber through the pupil and in to the anterior chamber. From the anterior chamber, the fluid is drained into the vascular system via the trabecular meshwork and Schlemm canal contained within the angle (the junction of the iris and cornea at the periphery of the anterior chamber).
AACG is caused by factors that either push or pull the iris up into the angle thus blocking the drainage of aqueous humour, raising the IOP and damaging the optic nerve (see ).
Image replicated with the kind permission of the Glaucoma Research Foundation (www.glaucoma.org).
AACG arises chiefly through a mechanism named pupillary block secondary to mydriasis. As the iris dilates and is pulled centripetally and posteriorly causing iris-lens contact, aqueous humour is prevented from passing between the lens and the iris into the anterior chamber. However, aqueous humour continues to be produced by the ciliary body pushing the peripheral iris anteriorly and thus closing the angle. The resultant effect is to obstruct aqueous outflow and cause a rapid onset of severe intraocular hypertension.
A further cause of acute angle closure occurs via the non-pupillary block mechanism, whereby the ciliary body is displaced forward shallowing the peripheral anterior chamber.
Signs and symptoms
AACG usually presents as a rapid progressive visual impairment in one or both eyes with severe ocular and periocular pain and patients may complain of nausea and vomiting. The pupil is often fixed and semi-dilated with corneal oedema and ocular redness. On examination, the IOP will be raised (above 21 mmHg) and the optic disc appears cupped.1,2
AACG in the critically unwell patient and patients in the post-operative period can be particularly challenging to diagnose. Often patients are sedated or have an altered mental status rendering the patient either unaware or unable to communicate pain. In these instances, a clinician must rely on the physiological signs often associated with a painful stimulus, such as a rise in heart rate or blood pressure along with characteristic ocular findings on examination. Even in awake patients, the early non-specific symptoms such as nausea, vomiting and headache are often attributed to other, more common pathologies.
Risk factors: Patient factors
Predisposing factors include being female, of East Asian descent, having a short axial length (hypermetropia) and a shallow anterior chamber, history of glaucoma, increasing age, thick lens and having a small corneal diameter and a positive family history.1–3
AACG is a recognised albeit uncommon complication of critical illness and general anaesthesia. Case reports have identified risk factors specific to anaesthesia and critical care. They include general risk factors such as prone positioning, and risk factors that are thought to cause pupillary block secondary to mydriasis. These include the use of vasopressors and bronchodilators, post-operative care in a darkened room and psychological stress.4–6 Common causative agents are listed in .3
Common agents implicated in the development of AACG.
|Topical eye drops||Atropine, tropicamide||Phenylephrine|
|Local absorption (nebulisers)||Ipratropium bromide||Salbutamol|
|Systemic||Tricyclic antidepressants Antihistamines Atropine||Nasal: ephedrine/cocaine Vasopressors/inotropes: adrenaline, noradrenaline, dopamine, ephedrine, phenylephedrine Bronchodilators: salbutamol, terbutaline||Sulphamate derivatives: Anticonvulsants: topiramate Antibiotics: Clotrimoxazole Selective serotonin re-uptake inhibitors Botulinum toxin Steroids|
AACG is a rapidly developing ophthalmic emergency with potentially disastrous effects. This rare but treatable condition can cause major morbidity in our patients and requires a high index of suspicion and vigilance for successful diagnosis and prompt management.
Many critically ill patients fall in to high-risk categories and predisposing risk factors should be considered during history taking. These include patient factors such as advanced age and short sightedness, and medical history including pre-existing eye disease and the use of topical medications. The precipitating cause for critical care admission and the pharmacological agents used for their treatment can precipitate AACG, in particular sepsis and obstructive airways disease. In addition, our patients are particularly vulnerable as they are often unable to communicate their symptoms due to sedation, delirium or weakness.
Clinicians should consider adapting routine pain and eye assessments on critical care for susceptible patients to take in to account eye pain and a global eye examination in addition to routine pupillary checks. Referral and treatment should be sought early in suspected cases of AACG and consideration should be given to the potential difficulty in accessing out of hours emergency ophthalmology services in a critical care environment.
We would like to thank Ms Bina Patel for her ophthalmology expertise and advice.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
1. The College of Optometrists. Clinical management guidelines: primary angle closure glaucoma. London: The College of Optometrists, 2013.
2. American Optometric Association. Optometric clinical practice guideline: care of the patient with primary angle closure glaucoma; Reference Guide for Clinicians. St. Louis, MO: American Optometric Association. 1994; last reviewed 2001.
3. Lai J, Gangwani R.
Medication-induced acute angle closure attack. Hong Kong Med J
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What Methods Are Available to Break an Acute Attack of Angle-Closure Glaucoma?
September 18, 2020
5 min read
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An acute angle-closure glaucoma attack is one of the few true ophthalmic emergencies. Presenting symptoms include severe eye pain or pressure sensation, redness, blurred vision, seeing haloes around lights, and nausea and vomiting. Sometimes, the person will describe prior milder episodes of these symptoms in the affected or fellow eye. The exam reveals conjunctival hyperemia, corneal microcystic edema, shallow peripheral anterior chamber, and nonreactive, mid-dilated pupil. If the corneal edema is not too severe, anterior chamber cells may be seen and the optic disc may be swollen. Intraocular pressure (IOP) is usually very high (>40 mm Hg). On gonioscopy of the involved eye, the angle is closed but indentation may open the angle in some areas; in the contralateral eye, the angle is usually narrow or appositionally closed, particularly superiorly, and peripheral anterior synechiae may be present.
Attempts to lower IOP should be started promptly after the diagnosis of acute angle-closure glaucoma is made because the acute pressure elevation can cause significant optic nerve damage within hours. Although laser iridotomy is the definitive treatment for acute angle-closure glaucoma,1 corneal edema may impair visualization and it is often very difficult to perforate the inflamed, edematous iris during an acute attack. Thus, immediate treatment should begin with corneal compression and medical therapy.
Corneal compression can be successful in some cases early in the attack. Indentation gonioscopy allows visualization of the angle to see if the angle opens up. You should push the gonioprism posteriorly into the central cornea and toward the mirror you are looking into so that the peripheral cornea vaults over the visible angle. This increases the chamber angle in the viewing quadrant. You can also indent the cornea with a moistened cotton-tip applicator. Note that the corneal epithelium is often edematous and prone to sloughing off with corneal compression and gonioscopy. Try these maneuvers for 30 seconds and if they do not break the attack, proceed with medical therapy.
The immediate goal of medical therapy is to lower the IOP. First, you should administer agents that decrease aqueous production, including a topical beta-blocker, a topical carbonic anhydrase inhibitor, and an alpha-agonist. Oral or intravenous acetazolamide can also be given. You should also initiate topical steroid therapy (one drop every 20 minutes) to reduce the inflammation associated with the attack. If the affected eye is phakic, give pilocarpine 1% to 2% to help constrict the pupil and break the pupillary block. Miotic therapy is frequently not effective until the IOP has been reduced, because of pressure-induced ischemia of the iris and paralysis of the sphincter muscle, so administration of pilocarpine should follow administration of the aqueous production inhibitors. For aphakic or pseudophakic eyes, pupil-dilating drops should be given instead. Osmotic agents, such as oral isosorbide or intravenous mannitol, are commonly used in conjunction with these other drugs.
If medical therapy is not successful in breaking an attack of acute angle-closure glaucoma after 1 hour, you should consider several additional treatment options. Laser iridotomy is the definite treatment to break the attack and reduce the risk of additional attacks. Nd:YAG laser iridotomy is often successful in breaking an attack, especially in eyes with light-colored irises. However, perforating an edematous, inflamed, thick brown iris may be difficult. Thus, for these cases my preference is to first perform laser peripheral iridoplasty with an argon or diode laser.2 The goal is to pull the peripheral iris away from the trabecular meshwork and allow aqueous to pass through. Using a large spot size (500 to 1000 μm), long duration (0.5 to 1 second), and low energy (100 to 250 mW), you should apply the laser spots to the far periphery with an iridotomy lens. Adjust the laser power to give a noticeable shrinkage of the iris tissue. About one spot per clock hour is sufficient and in most cases, the attack will usually break after a few shots. You will notice a deepening of the peripheral anterior chamber under the iridotomy lens and the patient will notice prompt relief of the pain. It is worthwhile to complete the 12 iridoplasty spots to reduce the chances of a recurrent attack prior to definitive iridotomy treatment. Unlike laser iridotomy, peripheral iridoplasty works well with iris edema and inflammation and even moderate corneal edema. Laser peripheral iridoplasty can also be performed as first-line treatment, prior to starting medical therapy, for rapid relief of an acute attack.3 As an alternative to peripheral iridoplasty, a pupilloplasty can also break the pupillary block by pulling the iris pupil margin away from the anterior lens surface. Again, you are trying to achieve visible shrinking of iris tissue. Pupilloplasty may leave a noticeable distortion of the pupil afterwards. However, the pupil may remain irregular after an acute angle-closure attack itself due to ischemic damage to the iris sphincter.
Some clinicians advocate performing an anterior chamber paracentesis to break an acute angle-closure glaucoma attack.4 The resultant IOP drop may be sufficient to allow the pupil to react to the pilocarpine and thus break the pupillary block. If necessary, you can use a blunt cannula to push the peripheral iris posteriorly to open up the adjacent angle and relieve the attack. In my opinion, a paracentesis carries a higher risk of complication than a laser peripheral iridoplasty or pupilloplasty.
If the attack breaks with medical therapy, iridoplasty, pupilloplasty, or paracentesis, the patient will need to have a laser iridotomy in both eyes. Optimally, however, you should defer laser iridotomy in the involved eye until the cornea is clearer and the intraocular inflammation has improved, typically in 1 or 2 days, but occasionally longer (Figure 23-1). During or immediately after an acute attack, the iris is edematous and inflamed, such that achieving a successful laser iridotomy is more difficult. After breaking the initial attack, you should send the patient home on topical beta-blocker, topical carbonic anhydrase inhibitor, topical alpha-2 agonist, topical pilocarpine, and topical steroid. Emphasize to the patient that bilateral laser iridotomies are needed to prevent another attack in either eye.
Figure 23-1. Persistent corneal edema 3 days after acute angleclosure attack. (Courtesy of Dale K. Heuer, MD.)
In rare instances, an acute angle-closure attack cannot be broken with the methods described above. You should then perform a definitive incisional peripheral iridectomy emergently in an operating room. Do remember that the IOP often remains elevated after an angle-closure attack and so plan your surgical iridectomy with the possibility that further glaucoma surgery may be needed in the future. Thus, you should use a clear corneal approach for the surgical iridectomy so the superior conjunctiva is not compromised.
As an alternative to incisional peripheral iridectomy, phacoemulsification with intraocular lens implantation, with or without goniosynechialysis, has also been advocated in recalcitrant cases of acute angle closure glaucoma.5 The pupillary block is relieved intraoperatively and the chamber angle widened with replacement of the natural lens with a thinner intraocular lens implant.
If a surgical intervention is performed, remember to do a laser iridotomy in the contralateral eye if it is at risk for angle closure.
1. Saw SM, Gazzard G, Friedman DS. Interventions for angle-closure glaucoma: an evidence-based update. Ophthalmology. 2003;110:1869-1878.
2. Lam DSC, Lai JSM, Tham CCY, Chua JKH, Poon ASY. Argon laser peripheral iridoplasty versus conventional systemic medical therapy in treatment of acute primary angle-closure glaucoma: a prospective, randomized, controlled trial. Ophthalmology. 2002;109:1591-1596.
3. Ritch R, Tham CC, Lam DS. Argon laser peripheral iridoplasty (ALPI): an update. Surv Ophthalmol. 2007; 52:279-288.
4. Lam DS, Chua JK, Tham CC, Lai JS. Efficacy and safety of immediate anterior chamber paracentesis in the treatment of acute primary angle-closure glaucoma: a pilot study. Ophthalmology. 2002;109:64-70.
5. Harasymowycz PJ, Papamatheakis DG, Ahmed I, et al. Phacoemulsification and goniosynechialysis in the management of unresponsive primary angle closure. J Glaucoma. 2005;14:186-189.
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Glaucoma – NHS
Glaucoma is a common eye condition where the optic nerve, which connects the eye to the brain, becomes damaged.
It’s usually caused by fluid building up in the front part of the eye, which increases pressure inside the eye.
Glaucoma can lead to loss of vision if it’s not diagnosed and treated early.
It can affect people of all ages, but is most common in adults in their 70s and 80s.
Symptoms of glaucoma
Glaucoma does not usually cause any symptoms to begin with.
It tends to develop slowly over many years and affects the edges of your vision (peripheral vision) first.
For this reason, many people do not realise they have glaucoma, and it’s often only picked up during a routine eye test.
If you do notice any symptoms, they might include blurred vision, or seeing rainbow-coloured circles around bright lights.
Both eyes are usually affected, although it may be worse in 1 eye.
Very occasionally, glaucoma can develop suddenly and cause:
- intense eye pain
- nausea and vomiting
- a red eye
- a headache
- tenderness around the eyes
- seeing rings around lights
- blurred vision
When to get medical advice
Visit an opticians or a GP if you have any concerns about your vision.
If you have glaucoma, early diagnosis and treatment can help stop your vision getting worse.
Without treatment, glaucoma can eventually lead to blindness.
If you develop symptoms of glaucoma suddenly, go to your nearest eye casualty unit or A&E as soon as possible.
This is a medical emergency that may require immediate treatment.
Types of glaucoma
There are several different types of glaucoma.
The most common is called primary open angle glaucoma. This tends to develop slowly over many years.
It’s caused by the drainage channels in the eye becoming gradually clogged over time.
Other types of glaucoma include:
- acute angle closure glaucoma – an uncommon type caused by the drainage in the eye becoming suddenly blocked, which can raise the pressure inside the eye very quickly
- secondary glaucoma – caused by an underlying eye condition, such as inflammation of the eye (uveitis)
- childhood glaucoma (congenital glaucoma) – a rare type that occurs in very young children, caused by an abnormality of the eye
Causes of glaucoma
Glaucoma can occur for a number of reasons.
Most cases are caused by a build-up of pressure in the eye when fluid is unable to drain properly.
This increase in pressure then damages the nerve that connects the eye to the brain (optic nerve).
It’s often unclear why this happens, although certain things can increase the risk, including:
- your age – glaucoma becomes more common as you get older
- your ethnicity – people of African, Caribbean or Asian origin are at a higher risk
- your family history – you’re more likely to develop glaucoma if you have a parent or sibling with the condition
- other medical conditions – such as short-sightedness, long-sightedness and diabetes
It’s not clear whether you can do anything to prevent glaucoma, but having regular eye tests should pick it up as early as possible.
Tests for glaucoma
Glaucoma can usually be detected during a routine eye test at an opticians, often before it causes any noticeable symptoms.
The tests are carried out in the opticians by an optometrist.
You should have a routine eye test at least every 2 years.
Find out if you’re eligible for free NHS eye tests
Several quick and painless tests can be carried out to check for glaucoma, including vision tests and measurements of the pressure inside your eye.
If tests suggest you have glaucoma, you should be referred to a specialist eye doctor (ophthalmologist) to discuss treatment.
Find out how glaucoma is diagnosed
Treatments for glaucoma
It’s not possible to reverse any loss of vision that occurred before glaucoma was diagnosed, but treatment can help stop your vision getting worse.
The treatment recommended for you will depend on the type of glaucoma you have, but the options are:
- eyedrops – to reduce the pressure in your eyes
- laser treatment – to open up the blocked drainage tubes or reduce the production of fluid in your eyes
- surgery – to improve the drainage of fluid
You’ll also probably need regular appointments to monitor your condition and check the treatment is working.
Further support for glaucoma
The Royal National Institute of Blind People (RNIB) and the International Glaucoma Association have more information on glaucoma and offer further support for people affected by glaucoma.
In this video, an expert explains what glaucoma is, how it can affect your vision and how it can be treated.
Media last reviewed: 1 June 2020
Media review due: 1 June 2023
Page last reviewed: 26 February 2021
Next review due: 26 February 2024
90,000 Angle-closure glaucoma: symptoms, treatment, recommendations
The term “glaucoma” unites a large group of diseases of the organs of vision, which are characterized by the following symptoms: high intraocular pressure, decreased peripheral vision and atrophy of the optic nerve. These changes lead to irreversible deterioration of vision up to the development of complete blindness. In Russia, the main cause of vision disability (up to 28%) is glaucoma.
What is angle-closure glaucoma of the eye?
Closed-back glaucoma is a pathology resulting from a disorder of the microcirculation of the intraocular fluid when the anterior corner of the eye overlaps.In the eye, aqueous humor is constantly produced, which is necessary for nourishing those internal structures where there are no blood vessels. The fluid through the drainage system, located in the anterior corner of the eye, flows into the superficial veins of the sclera. When outflow is disturbed, fluid accumulates, intraocular pressure increases. Irritation of pain receptors causes a further reactive rise in pressure. Compression leads to disruption of blood supply, dystrophy and atrophy of nerve fibers, which gradually causes atrophy and death of the optic nerve.
Scientists have come to the conclusion that the development and progression of glaucoma is a combined action of various risk factors that trigger the mechanism of the disease.
- Age category over 40.
- Race. People of the Negroid and Mongoloid races are most susceptible to pathology.
- Hereditary predisposition.
- Refractive error: high degrees of myopia or hyperopia.
- Condition after eye injury or the consequences of surgical operations.
- Frequently recurring stressful situations.
- Chronic cardiovascular diseases.
- Endocrine pathologies.
Stages of the pathological process in glaucoma:
- Disturbance of the circulation of the ophthalmic fluid.
- High intraocular pressure.
- Deterioration of blood supply to the tissues and structures of the eye.
- Increase in destructive-dystrophic processes leading to atrophy of the optic fibers.
- Formation of glaucomatous optic neuropathy.
Forms of angle-closure glaucoma
The most common forms (up to 80%) include glaucoma caused by pupillary block. The seizure periods are followed by asymptomatic remissions. Each attack leaves adhesions in the drainage system, which further disrupts the normal outflow of ocular fluid.Due to this, a constantly high pressure in the anterior chamber of the eye is maintained, which is accompanied by disorders of visual functions typical for glaucoma.
Angle-closure glaucoma with flat iris occurs in 10% of all cases. An exacerbation can develop when the pupil expands under the influence of various reasons: under stress, in the dark, when mydriatic drops are instilled into the eye.
In 7%, a “creeping” form is observed, in which, for unknown reasons, the root of the iris is fused with the angle of the anterior chamber.The disease begins imperceptibly and is often detected by chance during preventive examinations of the organ of vision. Later, ophthalmic hypertension and a typical clinical picture of angle-closure glaucoma join.
Glaucoma with vitreous lens block belongs to the rarest (about 1%) malignant form. Its appearance is associated with the anatomical and physiological features of the eye: an enlarged lens, a small size of the eyeball, a dense ciliary body. The iris-lens septum tilts anteriorly and obstructs the angle of the anterior chamber, while fluid collects behind the vitreous in the posterior chamber of the eye.
Symptoms of angle-closure glaucoma
The initial stages of the pathological process develop imperceptibly for the patient.
Symptoms of the disease are manifested during attacks, without exacerbation, there are no symptoms.
In the clinic of angle-closure glaucoma, acute and subacute attacks are distinguished.
An acute attack begins suddenly with the appearance of a sharp pain in the eye with irradiation on the affected side along the projection of the trigeminal nerve to the forehead and temples, vision becomes clouded, circles of all colors of the rainbow appear when looking at bright light.The general condition is also deteriorating: malaise, weakness, pain in the heart, nausea, vomiting.
The sclera are hyperemic, the cornea is edematous, the pupil is sharply dilated, deformed; there are foci of opacity on the lens.
An acute attack is characterized by a maximum rise in intraocular pressure. Rough adhesions that form in the anterior corner of the eye between the root of the iris and the cornea completely block the drainage system. With strong compression of the vessels of the iris, a local circulatory disorder develops, from which the optic nerve also suffers.
In a subacute attack, the angle of the anterior chamber of the eye is partially closed, which determines the clinical picture of the disease. With a mild course (intraocular pressure 40 mm Hg), when at least a minimal circulatory movement of the eye fluid is maintained, the patient has only foggy fuzzy vision and multi-colored circles in front of the eyes in bright light.
At a pressure above 60 mm Hg. Art. the symptoms of glaucoma become more pronounced: there are painful sensations in the eye, forehead, eyebrows.The subacute form does not cause deformation of the pupil, does not provoke the development of segmental atrophies and adhesions in the corner of the anterior chamber of the eye.
Most often, the motive for the development of an acute attack of glaucoma is:
- Emotional overexcitement.
- Physical work, associated with frequent bending of the trunk.
- Drinking too much liquid.
- Prolonged stay in a darkened room.
- Taking alcohol and medications that stimulate the nervous system.
In modern ophthalmology, several methods are used to diagnose glaucoma:
- Visometry – determination of visual acuity.
- Gonioscopy – assessment of the condition of the anterior chamber of the eye.
- Ocular tonometry – measurement of intraocular pressure.
Treatment of angle-closure glaucoma
Tactics for the treatment of angle-closure glaucoma is different and depends on the clinical picture of the disease.
In an acute attack of glaucoma, medical attention should be provided immediately, since prolonged exposure to high pressure structures of the eye can lead to complete loss of visual functions.
Medicines used in acute attack of glaucoma:
Eye drops with β-blockers that reduce the production of intraocular fluid: Glaumol, Okukap.
Drops with medicines, constricting the pupil. The pupil, contracting, pulls the iris behind it, which allows it to move away from the corner of the anterior chamber and unblock the outflow of fluid: “Pilocarpine”, “Oftan”.
Diuretics, analgesics and antiemetics are used as systemic pharmaceuticals.
If an attack of glaucoma lasts more than 24 hours, and drug treatment is ineffective, surgical treatment is indicated. If the attack stops, then the operation is performed at a more distant time.
Methods of surgical treatment of angle-closure glaucoma are determined by the form, stage and presence of concomitant pathologies.
Surgical treatment of angle-closure glaucoma consists in creating artificial micro-holes at the root of the iris, which closes the entrance to the drainage system.The operation is called iridectomy, while the anterior corner of the eye is slightly opened, and the pressure between the anterior and posterior chambers is equalized.
Laser iridotomy is also used in ophthalmology to treat glaucoma. The purpose of the operation is to form a channel between the anterior and posterior chambers of the eye, as a result of which the hydrostatic pressure is normalized.
In the clinic of Professor Trubilin, the method of non-penetrating deep sclerectomy is used as a surgical method for treating glaucoma.The operation is performed without opening the eyeball, only within the drainage system, which makes it possible to create a good hypotensive effect. In advanced clinical cases, it is proposed to implant a mini-shunt under the sclera, which will take over the function of drainage, through which the outflow of intraocular fluid will pass.
To navigate the question, what is angle-closure glaucoma should be all people. This is due to the insidiousness and unpredictability of this disease, from which no one is immune.As a preventive measure for the timely detection of pathology, it is recommended that people who have reached the age of 40 visit an ophthalmologist annually.
90,000 Acute attack of glaucoma – what is it, symptoms, diagnosis and treatment in the clinic
What is an acute attack of glaucoma?
Acute glaucoma is a dangerous condition that can result in permanent loss of vision and blindness. Such an attack develops due to a sudden and sharp increase in intraocular pressure, which is characteristic of angle-closure glaucoma – a disease caused by blocking access to the natural drainage system of the eye.
The risk of an acute attack is highest for the older generation – those who have crossed the 60-year mark. Although it can be diagnosed in people of any age, starting from infancy.
What factors can trigger an attack?
The following factors can provoke an acute attack of glaucoma:
- increased physical activity;
- long-term work requiring head tilt;
- strong negative emotions, excitement, stress;
- increase in blood pressure;
- the use of certain medications – certain types of antidepressants, eye drops to dilate the pupil, nasal drops with a vasoconstrictor effect, etc.;
- Consumption of alcohol, salted or pickled food;
- one-time use of a large amount of liquid.
90,013 eye injuries;
However, an acute attack of glaucoma can begin for no apparent reason, the specific triggers of this condition are not fully understood to date.
Symptoms of an acute attack of glaucoma
In view of the danger of serious complications, it is extremely important to recognize an acute attack of glaucoma in time – and take measures to stop it as soon as possible.
Differences between an attack of glaucoma and other dangerous conditions
Symptoms of an acute attack of glaucoma are often misinterpreted. A person experiencing such a condition, or his loved ones, may regard what is happening as an exacerbation of migraine, which really affects the eye area and is often accompanied by vomiting and temporary deterioration of vision, or, for example, as heart problems, due to which the necessary ophthalmological care is not provided in time. Treatment for other diseases begins, which only aggravates the situation.
However, it is still possible to distinguish a migraine or heart problem from a glaucoma attack. The fact that ophthalmological care is urgently needed is indicated by the following signs:
- corneal opacity;
- Immobility of the pupil and hardening of the eye;
- Immobility of the pupil and hardening of the eye;
- Marked redness of the eyes.
Instead of black in an acute attack of glaucoma, the pupil acquires a greenish tint.There may also be a decrease in the corneal reflex, manifested by the rapid closure of the eyelids as a reaction to mechanical stress on the cornea.
How to behave in case of an acute attack of glaucoma?
Intraocular pressure in patients with an acute attack of glaucoma is increased (up to 70-100 mm Hg), the eye is compacted, gives the impression of “stone”.
The main goal of treatment for an acute attack of glaucoma is to reduce intraocular pressure and normalize blood circulation in the eye to restore nutrition to the retina and optic nerve.
If symptoms of an acute attack appear, calm down and seek emergency medical attention. Before the arrival of specialists, you can make foot baths or apply mustard plasters to the calf muscles, this will help reduce blood flow to the head and eyes.
If it is not possible to remove the attack within 24 hours, the question of urgent surgical treatment may be raised.
Remember, self-medication in a situation of development of an acute attack of glaucoma is by no means worth it.If the help of qualified specialists is not provided on time, vision may be lost forever!
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Angle-closure glaucoma causes and symptoms of manifestation
Angle-closure glaucoma means IMPAIRMENT OF ACCESS TO THE DRAINAGE TUBES. Due to the blockage by different anatomical structures of the eye – the lens, the iris.
This is a rather rare form of glaucoma, which occurs in 10-20% of patients.There is a certain type of structure of the eyeball that predisposes to the occurrence of angle-closure glaucoma. This type of eye is often inherited from close relatives. The shortened size of the eyeball, large lens, small anterior chamber of the eye, thickened iris. All these features significantly increase the risk of developing angle-closure glaucoma, as well as the development of such a dangerous condition for vision as acute attack of angle-closure glaucoma .
With this disease, various symptoms may occur:
- mild (dull) or severe eye pain;
- Blurring of the picture, especially in the morning after sleep or during dusk;
- flicker before the eyes (like a rainbow when looking at the light).
If you notice something similar from the described symptoms, immediately contact your ophthalmologist for examination.
Acute attack of angle-closure glaucoma
It is important to know whether you have this disease, because with a severe attack of angle-closure glaucoma , the pressure inside the eye can rise very high, accompanied by a severe headache in the temples, and last for several hours, and sometimes and days.
The state of an acute attack of angle-closure glaucoma is an acute and serious condition that requires URGENT hospitalization and urgent treatment.A seizure usually occurs in one eye, which turns red and becomes unable to see clearly, while the other may be completely normal. The attack is often accompanied by severe nausea and vomiting. Sharp severe headache. If this happens to you or to someone close to you, immediately call an ambulance and have the patient a good ophthalmologist.
Again, these are extreme measures that can be avoided if the disease is diagnosed in time.
On the basis of the center “CLINIC ZIR” there is a full range of modern equipment that will help to diagnose before the appearance of an acute condition and severe vision loss.
Please note: characteristic symptoms in angle-closure glaucoma may not be present. This is a rather rare form of glaucoma that can develop in people over the age of 30 with farsightedness. You may not feel pain or visual impairment until an already protracted progression of the disease is detected.
Treatment of closed-type glaucoma in the center “CLINIC ZIR”
- An acute attack of the disease can be prevented if you consult a doctor in time and make the correct diagnosis in time.Correct diagnosis is the first step in successful treatment.
- A special group of antihypertensive drugs based on the substance pilocarpine is prescribed, which reduce intraocular pressure, constrict the pupil, and reduce the pressure of the anatomical structures of the eye on the drainage system.
- The arsenal to combat this type of glaucoma includes laser treatment – laser iridectomy. This procedure provides the formation of small holes in the iris, which serve as additional drainage.
- In an acute attack of angle-closure glaucoma, the standard of treatment is the surgical replacement of the natural enlarged lens with an artificial one, which is much narrower and allows fluid to enter the drainage system of the eye.
- Carrying out antiglaucoma surgery – making an additional hole in the eyeball through which excess fluid leaves the eye.
We invite you to the ophthalmological center “CLINIC ZIR”
If you notice any visual impairment, especially if they are accompanied by other symptoms (nausea, headache, dizziness, etc.), come to us for a consultation. An experienced ophthalmologist will examine you and, if necessary, carry out a comprehensive diagnosis. This way you will avoid unpleasant surprises and in case of any violations you will be able to detect and cure them in time.
Glaucoma: signs, symptoms, treatment and prevention. Does exercise help?
Glaucoma is often referred to as the “silent thief of vision” because most types of glaucoma do not cause pain or produce any symptoms until there is a noticeable loss of vision.
For this reason, glaucoma often progresses, remaining undetected until the optic nerve is irreversibly damaged.
What is glaucoma?
Glaucoma is a group of related visual disorders in which damage to the optic nerve, which carries information from the eye to the brain, occurs.
In most cases, glaucoma is associated with increased intraocular pressure, a condition called ocular hypertension. But it can also develop with normal intraocular pressure (IOP). If glaucoma is left untreated or controlled, peripheral vision loss will first occur and eventually blindness may occur.
In most types of glaucoma, damage to the optic nerve and loss of vision occurs due to too high intraocular pressure (IOP).
Glaucoma is the second most common cause of blindness worldwide (after cataracts).
Types of glaucoma
The two main categories of glaucoma are open-angle glaucoma and closed-angle glaucoma. In both cases, “angle” refers to the angle of the anterior chamber of the eye, which controls the outflow of clear fluid (aqueous humor) that is constantly formed inside the eye.
If aqueous humor freely penetrates into the corner of the anterior chamber of the eye, then glaucoma is called open-angle. If the angle of the anterior chamber of the eye is blocked, and aqueous humor cannot reach it, then glaucoma is called angle-closure.
Symptoms of glaucoma
Most types of glaucoma usually do not cause pain and produce no symptoms until there is a noticeable loss of vision, but in acute angle-closure glaucoma, a person experiences sudden symptoms: blurred vision, halos around light sources, intense eye pain, nausea and vomiting.
If you have these symptoms, see your optometrist so that steps can be taken to prevent permanent loss of vision.
Diagnostics, screening and tests to detect glaucoma
In routine eye examinations, a tonometer is used to measure intraocular pressure (IOP). Eye drops are usually instilled into the eye for numbness, and a small weight is gently placed on the surface of the eye. When measuring using another type of tonometer, an air stream is directed to the surface of the eye.
Abnormally high IOP readings indicate excess fluid (aqueous humor) in the eye. Either too much fluid is being produced in the eye, or it is not draining properly.
As a rule, the IOP should be below 21 mm Hg. Art. (millimeters of mercury) is a unit of measurement based on how much pressure occurs in a certain limited area.
If your IOP is above 30 mm Hg. Art., then the risk of loss of vision as a result of glaucoma is 40 times higher than in a person with an intraocular pressure of 15 mm Hg.Art. or below. Therefore, methods of treating glaucoma, for example, eye drops, have been developed to maintain a low IOP.
Other methods of glaucoma monitoring include the use of sophisticated imaging technology to create baseline images and assess the condition of the optic nerve and internal structures.
Then, at regular intervals, additional images are taken to assess the condition to make sure that there are no negative changes that may indicate the progressive nature of glaucoma.
Methods for treating glaucoma
Treatment for glaucoma may include surgery, laser treatment, or medication, depending on the severity. Usually, eye drops containing medications that work to lower IOP are tried first to control glaucoma.
Because glaucoma is often painless, it is not uncommon for people to take a strict eye drop regimen to control intraocular pressure and prevent permanent eye damage.
Indeed, one of the main causes of blindness due to glaucoma is non-adherence to the prescribed glaucoma treatment regimen.
If you experience any discomfort when applying eye drops for glaucoma, then never stop using them without first consulting an optometrist about possible alternative treatments.
Exercise May Reduce The Risk Of Glaucoma
Is It Possible To Reduce The Risk Of Glaucoma? According to a recent study in Europe, exercise reduces the likelihood of glaucoma in some people because it increases blood flow throughout the body and in the eyes.
In addition to regular exercise and an active lifestyle, you can reduce the risk of developing glaucoma through smoking cessation, maintaining a healthy weight, and a varied healthy diet.
Page published in November 2020
Page updated April 2021
Surgical treatment of glaucoma
According to data obtained in the WHO, approximately 13.5% of all blind people have lost their sight precisely because of glaucoma.Unbeknownst to himself and irrevocably, the patient loses primarily peripheral vision. Therefore, regular and comprehensive examinations by an ophthalmologist will identify the disease, correctly prescribe treatment and monitor its effectiveness.
By the type of disturbance in the functioning of the outflow of the eye fluid, the following forms are distinguished: angle-closure glaucoma, open-angle and mixed glaucoma.
Depending on what and when triggered the development of glaucoma, it happens:
And also there are:
- Congenital glaucoma.
- Juvenile glaucoma.
Open-angle glaucoma develops imperceptibly and accounts for about 90% of all detected cases. In this type of glaucoma, access to the drainage system is open, but the working functions of the intraocular fluid outflow apparatus are impaired, as a result of which the intraocular pressure slowly increases, sometimes for many years. As a result, a person may simply go blind imperceptibly.
Angle-closure glaucoma is acute and noticeable for the patient. Access to drainage canals is impaired, intraocular pressure rises rapidly, causing sharp pain in the eyes and head, redness and an acute decrease in vision.
Congenital glaucoma – a pathology associated with anomalies in the development of the eyeball, is detected in the first days (months) after the birth of the child.
The presence of increased IOP may be indicated by sharp discomfort in the eyes, iridescent circles when looking at a light source, a feeling of heaviness and “fog”.Vision decreases, especially at dusk. Its gradual narrowing to a small point is noted, corneal edema and redness of the anterior part of the eye may develop. The pupil expands and stops responding to light.
But more often than not, a person does not even suspect about the development of the disease. Moreover, during a routine medical examination, not every doctor can see developing glaucoma, even with the use of the most modern equipment.
Reasons for the emergence and development
Thanks to the correct and precise distribution of fluids within the eyes, ocular pressure is maintained.When the balance of inflow and outflow is disturbed, the pressure inside the eyeball begins to increase, all its structures are under stress. After that, blood circulation is disrupted, neurons die, signals do not enter the brain, the person gradually becomes blind.
Modern medicine identifies risk groups:
- Elderly people. Most of the diagnosed cases fall on the older age group (over 60 years old).
- Racial characteristics.The frequency and severity of the development of the disease in representatives of the Caucasian race is noticeably lower and easier than in people of the Negroid race.
- Diseases of the retina. Often, doctors associate the development of glaucoma with diseases of the retina.
- Myopia (myopia). In people with myopia, there is an increased ophthalmotonus, which damages the structure of the eyeball and provokes the development of IOP.
- Heredity. Direct relatives are at risk. The relationship and inheritance scheme has not been precisely found.However, to confirm the transmission of the disease by inheritance, doctors must constantly monitor the patient for several years. According to the latest data, the probability of developing glaucoma in children is 4%, in siblings it reaches 10%.
More often, the disease manifests itself in people after 65 years of age. Between the ages of 40 and 55, glaucoma is found in approximately 0.1% of the world’s population. Among infants, there is 1 case of congenital ailment per 10 thousand children.
So that the development of the disease does not drag on, experts recommend:
The first stage after the diagnosis of glaucoma is established, the patient is prescribed medication – instillation of eye drops that reduce intraocular pressure.
If therapy does not provide the desired result, laser or surgical intervention is required.
Unlike drops, which artificially maintain the balance of fluids in the eyeball, surgery completely restores this balance. This is a radical but effective and efficient procedure.
Remember ! By postponing your visit to your ophthalmologist and the treatment they are prescribed, you risk your eye health.
In each case, preparation for the operation is negotiated by the doctor individually.
Publications in the media
Angle-closure glaucoma is the result of a violation of the outflow of aqueous humor through the drainage system of the eye due to a decrease or complete closure of the angle of the anterior chamber formed by the root of the iris, the trabecular apparatus and the cornea. The closure of the anterior chamber angle occurs due to the functional pupillary block (the path of the outflow of aqueous humor from the posterior chamber of the eye to the anterior chamber).Angle-closure glaucoma is acute, subacute and chronic. The acute form of angle-closure glaucoma (acute attack of glaucoma) is an emergency that often results in loss of vision. Frequency. 5: 1000 population (2–2.5 times less common than open-angle glaucoma). It is estimated that in 2003 there will be 110 million patients with glaucoma, and 10 million blind from it. The second cause of acquired blindness after diabetes. The prevailing age is – 50–75 years. The predominant sex is female (2: 1).
Risk factors • Large lens • Shallow depth of the anterior chamber of the eye • Narrow angle of the anterior chamber • Relatively small size of the cornea • Hyperopic refraction.
Pathomorphology • Edema of all layers of the cornea and iris • Atrophic processes in the iris stroma, formation of goniosynechiae • Pupil deformity • Excavation of the optic nerve head • Atrophy of the optic nerve.
• Acute form (acute attack): •• Prodromal symptoms (sometimes the term “subacute attack” is used, because in some cases such symptoms bother the patient for a long time and do not lead to the development of an attack of acute glaucoma) ••• Periodic worsening of severity vision, iridescent circles when looking at a light source, dull pain in the eyeball, headache ••• Objectively – dilated, poorly responsive pupil, shallow depth of the anterior chamber (during this period, intraocular pressure [IOP] is usually not increased) •• • Symptoms occur with prolonged visual stress (reading, watching television, etc.)and stop after sleep or rest •• Typical attack of acute glaucoma (occurs after prodromal symptoms): ••• Sudden onset of severe throbbing pain in the eyeball (often in one), combined with a sharp deterioration or complete loss of vision. Pain radiates along the branches of the trigeminal nerve ••• Often an attack is accompanied by nausea and vomiting, which can lead to an erroneous diagnosis of a disease of the abdominal organs – red), corneal edema, a decrease in the depth of the anterior chamber, during gonioscopy – closing the angle of the anterior chamber with the root of the iris ••• IOP is significantly increased – 40–80 mm Hg.Art.
Chronic form •• IOP is also increased in the interictal period.
Research methods • Gonioscopy is a method for examining the angle of the anterior chamber of the eye, based on the use of special gonioscopic lenses.In an attack of acute angle-closure glaucoma, the angle is always closed; outside the attack, only its narrowing is often found • Measurement of IOP (see Notes ) • Ophthalmoscopy. In an attack of acute glaucoma, corneal edema sometimes prevents the fundus from being seen. In the later stages, glaucomatous excavation of the optic nerve head is detected. • Examination of the visual fields – progressive concentric narrowing, predominantly from the nasal side.
Differential diagnosis • Phakogenic glaucoma • Acute iridocyclitis • Secondary neoplastic glaucoma.
Mode. In case of an attack of acute glaucoma – inpatient (bed rest until relief of the attack), in other cases – outpatient.
• Acute glaucoma attack •• Sequential stepwise use of the following drugs: ••• A mixture of glycerin and water inside ••• Taking carbonic anhydrase inhibitors ••• Intravenous administration of osmotic agents (mannitol) and instillation of miotics (pilocarpine) and
b adrenergic blockers (timolol) •• Antiemetics (if necessary) •• After a decrease in IOP, the administration of carbonic anhydrase inhibitors and the instillation of miotics every 6 hours is indicated.
• Chronic angle-closure glaucoma – after diagnosis, the appointment of miotic drugs,
b -adrenergic blockers and carbonic anhydrase inhibitors is indicated until the implementation of surgical treatment. Long-term use of carbonic anhydrase inhibitors is contraindicated.
• Surgery – Peripheral laser iridotomy or iridectomy preferred. For the purpose of prophylaxis, the operation is also performed on the second eye, especially in the case of a narrowing of the angle of its anterior chamber.
• In acute glaucoma •• Glycerin 1-2 g / kg orally, after mixing with an equal volume of water (chilled and preferably with lemon juice) or •• Carbonic anhydrase inhibitors – acetazolamide acetazolamide 500 mg orally and instilling 1% p- brinzolamide and 0.25% solution of timolol 2 times a day, 1–4% solution of pilocarpine every 15 minutes for 1–2 hours. After normalization of IOP, acetazolamide is prescribed 250 mg every 6–12 hours and instilled into eyes of miotics, for example pilocarpine 1–2% solution 3–6 r / day ••
b -Adrenoblockers in eye drops every 12 hours – timolol 0.5% solution or betaxolol 0.5% solution •• Other drugs – clonidine 0.125-0.25% solution every 8 hours.
• In subacute and chronic forms – pilocarpine 1–2% solution 3–6 times per day, sometimes in combination with timolol 0.25–0.5% solution 1–2 times per day.
Complications • Chronic corneal edema • Fibrosis and vascularization of the cornea • Atrophy of the iris • Cataract • Subluxation of the lens • Atrophy of the optic nerve • Transition of glaucoma into a malignant form (malignant glaucoma) • Occlusion of the central veins of the retina or • Transition to the term …
Observation • In chronic form – IOP measurement and gonioscopy every 3 months after laser iridectomy, visual field examination every 6-12 months chronic form.
The course and prognosis vary depending on the timing and stage of glaucoma. The prognosis is the more favorable, the earlier the disease was diagnosed. In the later stages, complete loss of vision is possible (outcome in the form of terminal glaucoma).
Concomitant pathology. Hypermetropia.
ICD-10 • h50 Glaucoma
Notes • Drugs that often cause exacerbation of angle-closure glaucoma: systemic or local anticholinergic, local sympathomimetic, antihistamines • Measurement of IOP •• Normally, the true IOP is 10–21 mm Hg. Deviation by 3-5 mm Hg. should be regarded as hypertension or, conversely, hypotension of the eye. In persons over 70 years of age, IOP is somewhat lowered.In healthy people, IOP undergoes daily fluctuations – it rises slightly in the morning and at 11-12 o’clock in the afternoon; decreases in the evening • in the interictal period, IOP can be within the normal range •• IOP is increased during an attack of acute glaucoma to significant values (40–80 mm Hg). In chronic angle-closure glaucoma, the increase in IOP is often short-lived and occurs periodically throughout the day; It can be detected by a dark test: after measuring the IOP, the patient is placed in a dark room, where he spends 1 hour in a state of wakefulness in a prone position with the head end of the bed lowered.Then IOP is measured again – an increase of more than 6 mm Hg. indicates a predisposition to chronic angle-closure glaucoma.
90,000 12 rules for the prevention of glaucoma
The main danger of glaucoma is damage to the optic nerve and its atrophy, which significantly affects vision and can lead to complete blindness at an early age. What is the prevention of glaucoma read on.
How the disease develops
In a healthy eye, aqueous humor is constantly formed, which serves to wash the structures of the eyeball.This is how the cornea, lens and other elements are hydrated and nourished. Filtration and renewal of moisture is carried out through the trabecular network. The constant formation and change of this fluid allows the eye to be hydrated.
With glaucoma, too much intraocular fluid is formed, which does not have time to be excreted. As a result of the accumulation of moisture, intraocular pressure increases. In this state, the effect on the structures of the eye increases, but the optic nerve suffers most of all.
In most cases, the development of glaucoma is due to a hereditary predisposition. Since the disease is transmitted according to the polygenic type, its development and progression depends on the influence of external factors. Therefore, the prevention of glaucoma plays an important role.
A person cannot change the anatomical features of the structure of the eyeball, which predispose to the development of glaucoma, but you can always minimize the impact of dangerous factors.
Who Should Be Vigilant
People often confuse glaucoma with cataracts, believing that increased intraocular pressure is a problem in the elderly.Undoubtedly, there are more adult patients, but conditions in which intraocular pressure increases can be congenital or early acquired.
- relatives of patients with glaucoma;
- patients with diabetes mellitus;
- abusers of pupil dilation drugs;
90,013 elderly people;
90,013 patients with severe hyperopia, cataracts;
90,013 people with bad habits;
90,013 night shift workers.
Often, a person notices a problem only when the disease progresses to an advanced stage. At this stage, even competent treatment may be ineffective. People over 40 need to be more careful about their health, pay attention to symptoms.
Visual discomfort, rapid eye fatigue, discomfort (bloating in the morning, pain in the eyebrows, fogging, rainbow circles when looking at light sources) may indicate a problem.
If one family member is diagnosed with glaucoma, others should be screened regardless of age or symptoms.
Basic rules of prevention
Preventive measures help to reduce the damage that increased pressure causes to the visual system, that is, prevent optic nerve atrophy, blindness.
How to prevent glaucoma
- Do not overexert yourself. Both physical and psycho-emotional stress are subject to restrictions.
- Do not keep your head tilted. It is harmful for patients with glaucoma to engage in activities that require prolonged head bending forward. This applies to drawing, sketching, knitting, embroidery and similar activities. It is necessary to maintain a straight head position when working at a computer, watching television, reading.
- Adjust the correct lighting. It is dangerous for people with glaucoma to work in poor lighting conditions. It is important to make it as bright as possible so as not to strain your eyes.
- Give up bad habits. Smoking has an extremely negative effect on blood supply not only to the organs of vision. The transportation of oxygen and nutrients to all elements of the eyeball is disrupted.
- Do not wear clothing that interferes with blood circulation in the neck and head.
- Avoid eye fatigue. It is important to take breaks while working at the computer, reading and watching movies. It is recommended to set aside 10-15 minutes of rest every hour. At this time, you need to really rest, and not change one strenuous activity for another.
- Eat right. To prevent glaucoma, you need to include in the diet raw vegetables, fish, fruits, while reducing the amount of animal fats and sugar.
- Consume moderate amounts of water. Limiting the daily intake of water or other liquid is not worth it, if there is no doctor’s prescription for this. It is not always necessary to give up coffee or tea for glaucoma, but you should not drink more than one cup of any liquid at a time. As a safety net, you can check the reaction to coffee: measure the pressure before and after.
- Adequate rest, good sleep. Rest is an important preventive measure for many diseases. Eight hours of sleep from 10-12 pm is considered sufficient. It is advisable not to stay up late, to walk in the fresh air in the evening. It is necessary to sleep on high pillows. After waking up, it is recommended to do a warm-up right in bed.
- Do not give up medication.
- 11. Avoid sudden changes in lighting. This is especially true for people with angle-closure glaucoma.A sudden change in the intensity of lighting is a strong strain on the eyes, therefore, before going to the cinema, you need to use drops that prevent pupil dilation.
- 12. Constantly monitor your condition. Even with stable intraocular pressure, you need to see a doctor at least four times a year. These measures will help prevent glaucoma and other diseases of the visual system. Prevention is recommended not only for people with a predisposition, glaucoma can manifest itself even in a healthy person.
Glaucoma is a complication of many eye diseases. Its symptoms can appear after trauma, as well as with cataracts and refractive disorders, especially with severe hyperopia. These diseases provoke pupillary block and impaired circulation of intraocular fluid.
Moderate physical activity
Physical activity helps to normalize blood circulation in the visual system and prevent tissue hypoxia.However, for the prevention of glaucoma, it is necessary to exclude heavy lifting, it is allowed to lift objects up to 10 kg.
In case of stress it is necessary to take sedatives. If there is a predisposition, it can be dangerous to work in the summer cottage and in the garden. Prolonged tilting of the head is dangerous for people with glaucoma, because in this position the lens is displaced and makes it difficult for fluid to drain. Such actions are best carried out from a sitting position. You cannot tilt your torso at a fast pace, turn your head sharply and lift weights from 3 kg in one hand.
It is undesirable for people with a predisposition to engage in agricultural activities, construction, housework, which is associated with bending. People with diagnosed glaucoma should not do this at all. Risk factors can also include professional sports, gymnastics and yoga, especially upside-down positions. Weightlifting and similar sports are contraindicated.
Visual loads and lighting
One of the measures for the prevention of glaucoma is the limitation of visual stress and proper lighting of the workplace.
Must be limited to
90,012 90,013 read;
If these activities are related to the human profession, it is necessary to properly equip the workplace. Work at the computer must be dosed, taking breaks, doing gymnastics for the eyes. It is not recommended to work at night or in a changeable mode.Table lamps can be used to illuminate the work area.
Bright lighting is a risk factor. Glasses with green lenses are used to protect the eyes. It is noteworthy that dark glasses are contraindicated: they darken the situation too much and can only contribute to an increase in IOP. It is undesirable to drive for a long time in the dark, watch movies in bright or low light, sleep in a dark room.
Do not overheat and overcool.It is undesirable to visit the sauna and bathhouse, sunbathe for a long time, often use compresses and warming up. Indoors, you need to control the air temperature. With glaucoma, it is necessary to walk in the fresh air.
Patients with glaucoma do not tolerate temperature changes due to disturbances in vascular regulation. In particular, low temperatures are difficult to perceive, therefore, in winter, fluctuations in intraocular pressure are noted more often. Patients should not go outside in severe frost, take cold water procedures and walk in the cold.
Prevention of glaucoma consists in the use of products containing vitamins A, E and C. This is due to the antioxidant properties of these substances, and, as you know, it is the action of free radicals that negatively affects the organs of vision. Where to get vitamins:
- A: carrots, apples, potatoes, beets, cabbage, lettuce, red peppers, bananas, citrus fruits, apricots;
- E: sea fish, poultry, greens, leafy vegetables, vegetable oils;
- C: cabbage, spinach, red pepper, asparagus, tomatoes, citrus fruits, strawberries.
In addition to antioxidants, it is additionally recommended to take vitamins B1, B2, B6 and B12. B vitamins control oxidation, carbohydrate metabolism and cell growth. They are found in nuts, grains, dairy products, meat, and fish.
In case of visual impairment, everyone is advised to consume more wild berries and red grapes. Oatmeal, wheat and buckwheat porridge, dairy products, low-fat soups, legumes, bread (up to 200 g per day) will be useful. It is important to maintain normal bowel function.
It is important to restrict fluid to 1.5 liters per day. Water should enter the body evenly throughout the day. Eat less sour cream, butter, and easily digestible carbohydrates. Concentrated soups, salty dishes, organ meats, spices, pastries, strong coffee, tea, and alcohol can be dangerous.
The importance of preventive examinations
It is possible to detect increased intraocular pressure at the initial stage only at an appointment with an ophthalmologist.Modern devices allow you to correctly and accurately assess the state of the visual system and identify violations.
Secondary prevention of glaucoma
Secondary prevention refers to the measures that are carried out in the presence of a disease to stop its progression. It is an important part of glaucoma therapy that determines the rate of optic nerve atrophy. How to avoid acute attacks:
- Timely medication. A patient with glaucoma should regularly visit the ophthalmologist’s office and monitor his condition.Prescribed drugs should be used strictly according to the instructions or recommendations of the ophthalmologist.
- Balance your diet. For glaucoma, it is recommended to limit the amount of salt, sugary and pickled foods. The daily volume of liquid should not exceed 1.5 liters. It is advisable to give up alcoholic beverages.
- Limit loads. Intraocular pressure increases with physical and emotional stress, so risk factors (eye strain, improper lighting, head tilt, temperature changes, stress) should be avoided.When traveling abroad on vacation or permanently, it is recommended to take an extract from the medical history. In the event of an acute attack, doctors should know the details of the course of the disease and the treatment regimen. With increased intraocular pressure, it is categorically impossible to independently change the dosage of the prescribed drugs or cancel them.
Only an experienced ophthalmologist should recommend any antiglaucoma agents. It is impossible to completely cure glaucoma, so doctors strongly recommend prophylaxis.
People with a predisposition and diagnosed glaucoma are recommended to live in peace, without physical and nervous overload. It is important to follow the daily regimen, engage in moderate physical activity, and balance the diet.