Acute Angle Closure Glaucoma: Clinical Presentation
Acute angle closure glaucoma (AACG) presents with sudden onset of severe eye pain, blurred vision with halos around lights, eye redness, a mid-dilated poorly reactive pupil, corneal edema, and markedly elevated intraocular pressure, often accompanied by nausea, vomiting, and severe headache. 1, 2
Cardinal Ocular Symptoms
- Severe eye pain that is sudden in onset and may be accompanied by headache 1, 2, 3
- Blurred vision resulting from pressure-induced corneal edema creating a characteristic "steamy" or hazy corneal appearance 1, 4
- Halos around lights (multicolored haloes) due to corneal edema 1, 2
- Eye redness from conjunctival and episcleral vascular congestion secondary to markedly elevated IOP 1, 4
Systemic Symptoms
- Nausea and vomiting are systemic manifestations of the acute IOP spike 1, 2, 4
- Severe headache that may be the predominant presenting complaint 2, 3, 5
Key Physical Examination Findings
- Mid-dilated, poorly reactive or fixed pupil in the affected eye (may appear oval or asymmetric) 1, 4, 6
- Corneal edema with microcystic and stromal edema 1
- Conjunctival hyperemia (vascular congestion) 1
- Shallow anterior chamber on slit-lamp examination 1, 4
- Markedly elevated intraocular pressure (typically >40 mmHg) 2, 4
Intermittent Angle Closure Warning Symptoms
Patients may experience prodromal episodes before acute crisis that should never be dismissed as benign. 2, 6 These warning symptoms include:
- Transient blurred vision that resolves spontaneously 1, 2
- Halos around lights during episodes 1, 2
- Eye pain or headache following stress or dilated eye examination 1
- Symptoms triggered by dim lighting or pupil dilation 1
The presence of bilateral transient episodes with halos, opaque vision, and eye pain is pathognomonic for intermittent angle closure, which carries a 50% risk of acute crisis within 5 years if left untreated. 2, 6
Critical Clinical Pitfalls
Acute angle closure can rarely present without pain, mimicking amaurosis fugax or other painless causes of vision loss, making the diagnosis more challenging. 7 The American Academy of Ophthalmology emphasizes that transient symptoms should never be dismissed as benign, as these represent warning episodes before potentially blinding acute attacks. 2, 6
The fellow eye is at extremely high risk for developing acute angle closure, with untreated fellow phakic eyes having increased risk of acute attacks. 1 Eighteen percent of eyes become blind (10% from glaucoma) within 4-10 years following an untreated AACG. 1, 4
Medication-Induced Triggers
Patients should be specifically questioned about medications that may precipitate angle closure, including: 1
- Anticholinergic agents (antihistamines, motion-sickness medications, phenothiazines) 1, 8
- Adrenergic agents (decongestants, ephedrine, salbutamol inhalers) 1, 8
- Sulfa-based drugs (topiramate, acetazolamide, hydrochlorothiazide, cotrimoxazole) causing ciliary body edema 1, 8
- Antidepressants (tricyclic and tetracyclic) 1, 8