EM@3AM – Acute Angle Closure Glaucoma

Author: Erica Simon, DO, MHA (@E_M_Simon, EM Chief Resident, SAUSHEC, USAF) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Brit Long, MD (@long_brit, EM Attending Physician, SAUSHEC, USAF)

Welcome to EM@3AM, an emdocs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.


A 62 year-old female with a PMHx of hypertension presents for evaluation of severe left eye pain associated with blurred vision, headache, and nausea.  The patient reports the sudden onset of her symptoms as occurring 30 minutes prior to arrival while entering a movie theater. ROS is negative for sick contacts, ocular discharge, and foreign body sensation. The patient wears glasses that she is “unable to see without.”

Triage VS: HR 122, BP 132/91, RR 18, SpO2 98% RA
Corrected: OD 20/20, OS 20/200, OU 20/40

Ocular examination:
 OD:
-EOMI, PERRLA (3mm)
-No evidence of foreign body
-Fluorescein stain without uptake
-IOP 15 mmHg

OS:
-EOMI, pupil (5mm) mid-position and fixed, conjunctival injection, hazy cornea
-No evidence of foreign body
-Fluorescein stain without uptake
-IOP 34 mmHg

What is the patient’s diagnosis? What’s the next step in your evaluation and treatment?


Answer: Acute Angle Closure Glaucoma1-3

  • Risk Factors: hyperopia, age >60, female sex
  • Presentation: sudden onset, severe eye pain +/- blurred vision, +/- nausea or emesis, +/- headache, pupil mid-positioned +/- fixed or sluggish, IOP >20mmHg
  • Precipitating factors:
    • Transition to dim lighting
    • Medications
      • Anticholinergics (topicals: cyclopentolate, tropicamide, etc., or systemic: antihistamines, antipsychotics, anticonvulsants, anti-parkinsonian medications, atropine, etc.)
      • Adrenergic agents (vasoconstrictors, bronchodilators, appetite depressants, etc.)
    • Emotional stress/pain (mydriasis secondary to increased sympathetic tone)
  •  Treatment:
    • Consult ophthalmology
    • Decrease production of aqueous humor:
      • Beta blockade: timolol 0.5% gtt
      • Alpha-2 agonists: apraclonidine 1% gtt or brimonidine 0.2% gtt
      • Carbonic anhydrase inhibitors:
        • Acetazolamide gtt or dorzolamide 2% gtt + 500 mg PO or IV acetazolamide
    •   Improve outflow of aqueous humor:
      • Cholinergic agent: pilocarpine 2% gtt
    • Decrease volume of aqueous humor:
      • Osmotic diuretic: mannitol 1-2g/kg IV
  •  Pearls:  
    • Obtain a thorough medical history:
      • B-blockade: caution with heart blocks, history of severe bronchospasm
    • Carbonic anhydrase inhibitors: avoid in sickle cell patients
    • Pilocarpine therapy should not be initiated until one hour following the instillation of an aqueous humor reducing agent:
      • Pilocarpine constricts the ciliary muscle causing miosis and increasing the axial thickness of the lens. While this allows for increased outflow of aqueous humor, it may also paradoxically worsen the condition by reducing the depth of the anterior chamber.2
    •  Suspect medication induced acute angle closure glaucoma if elevated IOP is present bilaterally.4


References:

  1. Tintinalli J, Kelen G, Stapczynski J, Ma O, Cline D, et al. Tintinalli’s Emergency Medicine. 8th ed. New York: McGraw-Hill; 2016. Chapter 60, Aneurysmal Disease.
  2. Jovina S, Aquino M, Chew P. Angle-Closure Glaucoma. In Ophthalmology. 4th ed. Philadelphia, Elsevier 2014; 10.12: 1060-1069.e2.
  3. Day A, Nolan W, Malik A, Viswanathan A, Foster P. Pilocarpine induced acute angle closure. BMJ Case Rep. 2012; 2012.
  4. Aminlari A, East M, Wei W, Quillen D. Topiramate induced acute angle closure glaucoma. Open Ophthalmol J. 2008; 2:46-47.

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