What are the symptoms of acute angle-closure glaucoma?

Symptoms of Acute Angle-Closure Glaucoma

The classic symptoms of acute angle-closure glaucoma include severe eye pain, blurred vision, halos around lights, headache, nausea/vomiting, eye redness, and a mid-dilated pupil. 1

Key Clinical Presentation

Ocular Symptoms

• Eye pain: Severe, often described as a deep aching sensation
• Visual disturbances:
  • Blurred vision
  • Halos around lights (multicolored)
  • Decreased visual acuity
  • Potential for complete vision loss if untreated
• Eye appearance:
  • Conjunctival hyperemia (redness)
  • Episcleral vascular congestion
  • Mid-dilated pupil (often oval or irregular in shape)
  • Poor pupillary reactivity
  • Corneal edema (cloudy appearance)
  • Shallow anterior chamber

Systemic Symptoms

• Headache: Often severe, may be mistaken for migraine or cluster headache
• Nausea and vomiting: Due to severe pain and elevated intraocular pressure
• General discomfort: Can be significant enough to cause distress

Physical Examination Findings

• Intraocular pressure: Markedly elevated (often >40-50 mmHg)
• Cornea: Microcystic and stromal edema giving a cloudy appearance
• Anterior chamber: Shallow both centrally and peripherally
• Pupil: Mid-dilated, poorly reactive, may be oval-shaped
• Conjunctiva: Hyperemic (red)

Important Diagnostic Considerations

• Symptoms may occur spontaneously or following pharmacologic stress (anticholinergic medications, mydriatic eye drops) 2
• Symptoms may have been intermittent in the past (blurred vision, halos, eye pain, headache, redness) 2
• Patients may report symptoms following stress or dilated eye examination 2

Risk Factors to Consider

• Anatomical factors:
  • Hyperopia
  • Shallow anterior chamber depth
  • Short axial length
  • Thick crystalline lens
  • Steep corneal curvature
• Demographic factors:
  • Asian descent (particularly Chinese)
  • Older age (>50 years)
  • Female gender
  • Family history of angle closure 2, 1

Clinical Pitfalls and Caveats

• Acute angle-closure glaucoma can be misdiagnosed as:
  • Migraine headache
  • Cluster headache
  • Other causes of severe headache 3
• Certain medications can trigger acute angle closure in susceptible individuals:
  • Anticholinergics
  • Adrenergic agents
  • Sulfonamides (including topiramate)
  • Phenothiazines
  • Over-the-counter cold and flu medications containing anticholinergic compounds 2, 4

Importance of Prompt Recognition

• Acute angle-closure glaucoma is an ophthalmological emergency requiring immediate treatment
• Without prompt intervention, retinal nerve fiber layer damage occurs rapidly
• Permanent vision loss can develop, with 18% of eyes becoming blind following an acute attack 2, 1
• Same-day ophthalmology referral is essential when suspected 1
• The fellow eye should also be evaluated, as it is at high risk for developing acute angle closure 1

Remember that the clinical presentation may vary in severity, but the constellation of eye pain, visual disturbances, headache, nausea/vomiting, and eye redness with a mid-dilated pupil should prompt immediate consideration of acute angle-closure glaucoma.