In a 64-year-old hyperopic woman presenting with sudden severe unilateral ocular pain, headache, nausea, vomiting, blurred vision, halos around lights, and a mid‑dilated sluggish pupil, what is the most likely diagnosis?

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Acute Angle-Closure Glaucoma

The most likely diagnosis is A. Acute angle-closure glaucoma (AACG). This clinical presentation is pathognomonic for acute angle-closure crisis.

Clinical Reasoning

This 64-year-old hyperopic woman presents with the classic constellation of symptoms and signs that definitively establish AACG 1:

Key Diagnostic Features Present:

  • Sudden severe unilateral ocular pain with headache
  • Systemic symptoms: nausea and vomiting
  • Visual symptoms: blurred vision and halos around lights (from pressure-induced corneal edema)
  • Mid-dilated, sluggish pupil (pathognomonic finding due to pressure-induced ischemia of the pupillary sphincter)
  • Hyperopia (major risk factor)
  • Age 64 years and female gender (both established risk factors)

Why the Other Options Are Incorrect:

Anterior uveitis (B) typically presents with:

  • A small, constricted pupil (not mid-dilated)
  • Photophobia as a prominent feature
  • No halos around lights
  • Less severe systemic symptoms

Viral conjunctivitis (C) presents with:

  • Discharge and foreign body sensation
  • Normal pupil
  • No severe pain or systemic symptoms
  • No visual disturbances like halos

Scleritis (D) features:

  • Deep, boring pain that may radiate
  • Normal pupil
  • No halos or acute vision loss
  • No systemic gastrointestinal symptoms

Pathophysiology

The guideline clearly defines AACG as occurring when the anterior chamber angle becomes suddenly obstructed, causing rapid IOP elevation 1. In hyperopic eyes with anatomically narrow angles, pupillary block creates a pressure gradient between posterior and anterior chambers, causing anterior iris bowing that occludes the trabecular meshwork. The mid-dilated pupil occurs because the markedly elevated IOP causes ischemia of the pupillary sphincter, making it unresponsive 1.

Critical Clinical Pitfall

This is an ophthalmologic emergency requiring same-day treatment 2, 3. Even non-ophthalmologists can detect markedly elevated IOP by gentle palpation of the globe—the eye will feel rock-hard compared to the normal fellow eye 2. Delayed treatment causes irreversible damage to the optic nerve, trabecular meshwork, iris, lens, and cornea 1.

Immediate Management Algorithm

Per the 2021 Ophthalmology guidelines 1:

  1. Initiate medical therapy immediately to lower IOP and relieve symptoms:

    • Topical beta-blockers
    • Topical alpha-2 agonists
    • Topical/oral/IV carbonic anhydrase inhibitors
    • Topical parasympathomimetics (pilocarpine)—though may be ineffective if IOP is markedly elevated due to sphincter ischemia
    • Systemic hyperosmotic agents (oral glycerol or IV mannitol) for rapid IOP reduction

  2. Perform laser peripheral iridotomy as soon as possible once corneal edema clears—this is the definitive treatment with the most favorable risk-benefit ratio 1

  3. Treat the fellow eye prophylactically with laser iridotomy, as it has approximately 50% risk of similar attack 1

The diagnosis is unequivocal based on this presentation, and immediate ophthalmologic referral is mandatory to prevent permanent vision loss.

References

2
Research

Acute Closed-Angle Glaucoma-an Ophthalmological Emergency.

Deutsches Arzteblatt international, 2021

3
Research

Acute angle closure glaucoma.

British journal of hospital medicine (London, England : 2005), 2019

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.