ACUTE PRESENTATION

02: The Painful Red Eye

Acute Angle Closure and Angle Closure Glaucoma

FACT
sHEET

Presentation
A patient with acute angle closure or angle closure glaucoma
will be experiencing ocular pain which may be severe. Their
eye will be red, and they may complain of reduced vision
manifesting as a rapid, progressive impairment of vision in
one or both eyes.
The patient may be seeing haloes around lights, and
experiencing headaches, nausea and vomiting. Their pupil will
be in mid-dilation, and a vertical oval in shape.
Acute attacks of angle closure may be self-limited and resolve
spontaneously or may occur repeatedly. 50% of patients will
give a history of previous intermittent attacks.

Look for
In angle closure glaucoma the patients IOP will usually be
very high, between 40 and 100mmHg.
Examining the eye externally will show conjunctival
hyperaemia with circumcorneal injection with a violet hue.
Corneal oedema will be present, demonstrated by an irregular
corneal reflex. Although the eye may be tearing, there will be
no other discharge. The pupil will be unreactive and fixed in
mid-dilation with a vertically oval shape.
A slit lamp examination will reveal a shallow anterior chamber
and possible aqueous flare. Keratic precipitates and posterior
synechiae may also be observable. The patients fellow eye
generally shows an occludable angle.
If you observe the optic disc you may find it oedematous and
hyperaemic in severe attacks.
The patients visual acuity will usually be 6/60 to hand
movement.
Mid-dilated, vertically oval pupil

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Differential diagnosis
Acute anterior uveitis

Acute elevation of IOP

Lens-induced (Phacomorphic) angle-closure
Malignant glaucoma
Neovascular glaucoma
Inflammatory elevation with an open angle
Mechanical and postsurgical closure
Other causes of secondary angle-closure

Referral steps
Emergency referral to an ophthalmologist
Posterior synechiae

Further clinical management

Following the initial first aid, the patient could assume a supine position to encourage the lens to shift posteriorly under the influence
of gravity.
Acetazolamide (Diamox) should be given, typically intravenously followed by slow-release tablet form after one hour. If there is no
response, systemic hyperosmotics such as glycerol may be added. Patients should be offered systemic analgesia and antiemetics if
required.
The ophthalmologist may attempt corneal indentation with a gonioscopy lens or a cotton bud. Laser iridotomy is then the most likely
treatment option, although surgical treatment such as iridoplasty and lens extraction may also be considered.
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Red flag symptoms

Pain in or around the eye, haloes around lights, circum-corneal
injection, a mid-dilated, non-reactive pupil and significantly
elevated IOP.

References
1. Kanski JJ & Bowling B. Glaucoma. In: Clinical Ophthalmology2.

3.
4.

5.

A systematic approach, Seventh Edition. Elsevier Limited, 2011

Subak-Sharpe et al. Pharmacological and environmental
factors in primary angle-closure glaucoma. British Medical
Bulletin. 2010; 93: 125-143
Hiroshi S & Shoichi S. Acute angle-closure glaucoma.
Ophthalmology. 2005; 47(11): 1673-1681
Mahmood AR & Narang AT. Diagnosis and management of the
acute red eye. Emergency medicine clinics of North America.
2008; 26: 35-55.
The College of Optometrists. Glaucoma (primary angle
closure) (PACG). Clinical Management Guidelines. 2009

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