Case Report: Acute Angle-Closure Glaucoma in a 43-Year-Old Male

Introduction
Acute angle-closure glaucoma (AACG) is an ocular emergency resulting from a rapid increase in intraocular pressure (IOP) due to obstructed aqueous humor outflow. It is commonly associated with a shallow anterior chamber angle, predisposing individuals to blockage. Without timely intervention, AACG can lead to permanent vision loss or blindness. This report describes the presentation, diagnosis, and management of AACG in a patient presenting to the emergency room (ER).

Patient Presentation
A 43-year-old male with no significant past medical history presented to the ER on a Sunday afternoon with blurred vision and pain in the right eye that began the day before. He initially hoped the symptoms would resolve on their own but sought medical attention after consulting a healthcare provider. He reported a sharp, constant headache behind the right eye rated 6/10, accompanied by nausea and blurred vision, described as though a film was over the right eye. He also noticed mild redness in the right eye but denied discharge, pain with eye movement, photophobia, fever, chills, respiratory, gastrointestinal, or genitourinary symptoms.

Physical Examination

• Vital Signs: T 98.7°F, P 85 bpm, R 16/min, BP 151/87 mmHg, SpO₂ 97% on room air.Visual Acuity: Right Eye 20/40, Left Eye 20/20.
• Extraocular Movements (EOM): Full range of motion without pain.
• External Eye Exam: Eyelids everted—no foreign bodies. Mild conjunctival erythema, no discharge.
• Corneal Staining: Fluorescein stain showed no corneal uptake.
• Funduscopic Exam: Right Eye: Cloudy cornea, retina not visualized. Left
• Eye: Retina visualized, no gross abnormalities.
• Intraocular Pressure (IOP): Right Eye 76-80 mmHg, Left Eye 14-17 mmHg.
• Slit Lamp Exam: Not available in the ER.

Working Diagnosis
Acute Angle-Closure Glaucoma (AACG)

Treatment Provided in ER

• Acetazolamide (Diamox): 500 mg PO (IV formulation unavailable)
  Timolol 0.5%: 2 drops in the right eye
• Apraclonidine and Prednisolone ophthalmic solutions were not available.
• Ophthalmology Consultation: Arranged for evaluation in the next town within 2 hours.
• Patient Outcome: Vision significantly improved by the time of the ophthalmologist’s evaluation.

Ophthalmologist’s Evaluation and Follow-Up

• Visual Acuity: 20/30 in the right eye (improvement from 20/30)
• IOP: Right Eye: 40 mmHg
• Gonioscopy: Confirmed Angle-Closure Glaucoma
• Intervention:
  • Paracentesis performed the same night.
  • Laser Peripheral Iridotomy (LPI) scheduled for definitive treatment.

Discussion

Pathophysiology and Presentation
AACG occurs due to a sudden rise in IOP from obstructed aqueous humor outflow, typically in patients with a shallow anterior chamber angle. This narrowing predisposes individuals to blockage, leading to rapid pressure increase.

Typical Presentation

• Severe unilateral eye pain or headache, blurred vision with rainbow-colored halos, nausea and vomiting.
• Red eye with conjunctival injection but no discharge, cloudy cornea due to corneal edema.

Diagnosis

• OP Measurement: Typically 50 to 80 mmHg using tonometry.
• Slit Lamp Examination (if available) would show: shallow anterior chamber, fixed, mid-dilated pupil, corneal edema, ciliary flush, and closed angle on gonioscopy.

Management in ER
Rapid IOP reduction is essential:

• Oral or IV Acetazolamide: Carbonic anhydrase inhibitor to reduce aqueous humor production.
• IV Mannitol: Osmotic diuretic to decrease intraocular volume.
  Topical Beta-Blocker (Timolol 0.5%): Decreases aqueous humor production.
• Topical Alpha-2 Agonist (Apraclonidine 1%): Decreases aqueous production and enhances outflow.
• Topical Pilocarpine: Miotic agent to facilitate drainage, but only after IOP is below 40 mmHg.

Definitive Treatment

• Paracentesis: Performed to rapidly reduce IOP before LPI.
• Laser Peripheral Iridotomy (LPI): Creates a hole in the peripheral iris, allowing aqueous humor to bypass the pupil, preventing future episodes.

Complications

• Permanent Vision Loss or Blindness if untreated.
• Malignant Glaucoma (Aqueous Misdirection Syndrome or Ciliary Block Glaucoma): Characterized by increased IOP despite a patent iridotomy and a flat anterior chamber, leading to progressive blindness.

Conclusion
Acute angle-closure glaucoma requires immediate diagnosis and treatment to prevent irreversible vision loss. ER physicians should maintain a high index of suspicion in patients presenting with sudden eye pain, blurred vision, headache, and nausea. Rapid IOP measurement, ophthalmologic consultation, and medical management are crucial to achieving a favorable outcome. Delayed intervention may lead to optic nerve damage and permanent blindness.

 

By: Babak Imanoel, DO

This is for informational purposes only. For medical advice or diagnosis, consult a physician.