What are the symptoms and treatment options for closed angle glaucoma?

Closed Angle Glaucoma Symptoms and Treatment

Acute angle-closure crisis presents with a constellation of ocular and systemic symptoms including blurred vision with halos around lights, severe eye pain, headache, nausea/vomiting, mid-dilated pupil, conjunctival redness, and corneal edema—this is an ophthalmologic emergency requiring immediate IOP reduction and definitive laser iridotomy to prevent permanent blindness. 1, 2

Clinical Presentation

Acute Angle-Closure Crisis (AACC)

The hallmark symptoms result from rapidly elevated intraocular pressure and include:

Ocular symptoms:

• Blurred vision caused by pressure-induced corneal edema 1
• Halos around lights (multicolored) from corneal edema 1, 2
• Severe eye pain 1, 2
• Red eye from conjunctival and episcleral vascular congestion 1

Systemic symptoms:

• Headache 1, 2
• Nausea and vomiting 1

Physical examination findings:

• Mid-dilated, nonreactive pupil 1
• Corneal edema (microcystic and stromal) 1, 2
• Elevated IOP (often >40-50 mmHg) 3
• Lens opacities (glaucomflecken) 1

Chronic/Intermittent Angle Closure

Some patients experience intermittent episodes with transient symptoms that resolve spontaneously, representing warning signs before acute attacks 4:

• Transient blurred vision 4
• Halos around lights 4, 5
• Mild eye discomfort 4
• Episodes often occur in dim lighting or after pupil dilation 1

Critical pitfall: These transient symptoms should never be dismissed as benign—they represent intermittent pupillary block and predict future acute attacks 4.

Risk Factors

Demographic factors:

• Age >50 years 1, 2
• Female gender 1, 2
• Asian or Inuit ethnicity (highest prevalence) 1, 2
• Family history of angle-closure glaucoma 1, 2

Anatomic factors:

• Hyperopia 1, 2
• Short axial length 1, 2
• Shallow anterior chamber depth 1, 2
• Thick, anteriorly positioned crystalline lens 1, 2
• Steep corneal curvature 1, 2

Treatment Algorithm

Immediate Management of AACC

Step 1: Rapid IOP reduction with medical therapy 2

Administer multiple topical agents simultaneously:

• Topical beta-blockers (timolol 0.5%) 2, 6
• Topical alpha-2 agonists (apraclonidine or brimonidine) 2, 6
• Topical carbonic anhydrase inhibitors (dorzolamide or brinzolamide) 2, 6
• Topical parasympathomimetics (pilocarpine 1-2%, only after IOP begins to decrease) 2, 6

Add systemic agents:

• Oral acetazolamide 500 mg or IV acetazolamide 7, 6
• IV mannitol or oral glycerol (hyperosmotic agents) 2, 6

Step 2: Definitive treatment once IOP controlled 2

• Laser peripheral iridotomy (LPI) is the definitive treatment to relieve pupillary block 2, 4
• Verify iridotomy patency after procedure 2
• Treat the fellow eye prophylactically with LPI—untreated fellow eyes have approximately 50% risk of AACC within 5 years 4

Chronic Primary Angle-Closure Management

After LPI, perform dark-room gonioscopy to assess angle opening 2:

• If angle opens adequately: Monitor IOP and optic nerve 2
• If persistent angle closure or elevated IOP: Consider additional interventions 2

Treatment options for persistent disease:

• Topical ocular hypotensive agents (prostaglandin analogs, beta-blockers, etc.) 2, 6
• Laser iridoplasty for plateau iris configuration 2
• Lens extraction (cataract surgery)—growing evidence shows substantial IOP lowering in PAC/PACG patients 2
• Incisional glaucoma surgery if medical/laser therapy fails 2

Critical Pitfalls and Considerations

Diagnostic pitfalls:

• 28% of AACC patients initially present to non-ophthalmologists with headache, nausea, or pupil abnormalities, leading to unnecessary neurologic workup including CT scans (32%) and lumbar punctures (8%) 8
• Painless AACC can occur, mimicking amaurosis fugax or other transient vision loss 9
• Even non-ophthalmologists can detect markedly elevated IOP by gentle palpation of the globe (rock-hard eye) 10

Treatment pitfalls:

• Avoid pupil dilation in patients with suspected narrow angles until after iridotomy 4
• Do not delay fellow eye prophylaxis—acute attacks can occur within days 4
• Monitor for optic disc swelling after rapid IOP reduction with laser iridotomy 3
• Recognize plateau iris configuration—nearly one-third of PAC eyes retain significant iridotrabecular contact after iridotomy and may require additional treatment 1, 2

Prognostic considerations:

• Untreated AACC causes severe visual morbidity: 18% of eyes become blind and 58% have vision worse than 20/40 at 4-10 years 1, 2
• Glaucomatous optic neuropathy develops rapidly with untreated high IOP 1, 4
• Retinal nerve fiber layer changes occur within days to months after AACC (initial swelling, then atrophy) 1

Medication considerations:

• Avoid anticholinergic medications and sympathomimetics that can precipitate angle closure 1
• Sulfonamides (including topiramate) can cause ciliary body edema and angle narrowing 1
• Inhaled medications (ipratropium, albuterol) may have anticholinergic effects 1