History and exam

Key diagnostic factors

common

presence of risk factors

Key risk factors include female gender, Inuit or Asian ethnicity, hyperopia, use of medication that can induce angle narrowing, and shallow anterior chamber.

halos around lights

Present in the acute and sub-acute forms but not with the chronic form of angle closure.

aching eye or brow pain

Present in the acute and sub-acute forms but not with the chronic form of angle closure.

headache

A deep, dull, periocular ache may be present in the acute and sub-acute forms but not with the chronic form of angle closure.

nausea, vomiting

Present in the acute and sub-acute forms but not with the chronic form of angle closure.

reduced visual acuity

Present in the acute and sub-acute forms but usually not with the chronic form of angle closure.

eye redness

Attributable to vascular congestion. Present in the acute and sub-acute forms but not with the chronic form of angle closure.

elevated intraocular pressure (IOP)

In healthy eyes, IOP is generally 10-21 mmHg. In acute attacks, IOP rises rapidly to relatively high levels, typically above 40 mmHg. In chronic angle-closure glaucoma, the IOP may be variably elevated depending on the extent of angle closure.

corneal oedema

Present in the acute and sub-acute forms but not with the chronic form of angle closure.

fixed mid-dilated pupil

Iris ischaemia may cause the pupil to remain permanently fixed and dilated.

Present in the acute and sub-acute forms but not with the chronic form of angle closure.

Other diagnostic factors

common

use of drugs that induce angle narrowing

Sulfa-containing drugs (e.g., sulfonamides), diuretics (e.g., acetazolamide), topical pupil dilators (e.g., cyclopentolate, atropine), and anticonvulsants (e.g., topiramate) can precipitate angle-closure glaucoma by pupillary block and displacement of the lens-iris diaphragm.[16][17]

incidental eye findings

Chronic angle-closure glaucoma (ACG) may be detected incidentally at routine eye examination.

These patients may be mostly asymptomatic with intermittent and/or recurrent angle closure symptoms (e.g., intermittent ache and/or blurred vision with halos around lights [which resolve spontaneously]), and/or with risk factors for ACG.

blurred vision

Present in the acute and sub-acute forms but not with the chronic form of angle closure.

corneal hysteresis

Generally low in glaucoma. Lower values may be associated with an increased risk of glaucoma progression.[28]

uncommon

change in vision

In effect this is new recognition of long-standing chronic progressive visual field loss.

Risk factors

strong

female sex

Women are at increased risk of developing angle-closure glaucoma compared with men.[4][7][8]

Some experts believe that sex hormones in pre-menopausal women confer a protective effect that is then lost once women enter the menopause.[8]

hyperopia

The anterior chamber depth and volume are smaller in hyperopic eyes (farsighted).[19][20][21][22]

shallow peripheral anterior chamber

Having smaller anterior segment dimensions is the main ocular risk factor for closure of the angle, with anterior chamber depth having the strongest correlation with angle closure and angle-closure glaucoma.[23][24]

angle closure in the fellow eye

An untreated fellow eye has a 40% to 80% chance of developing an acute episode of angle closure over the next 5-10 years.[1]​​ It can, however, happen within days.[1]

Premised on the fellow eye having the same anatomical predisposition.

Asian and Inuit ethnicity

The highest rates of ACG are reported in Asian and Inuit populations.[2][4]​​[9]

advanced age

ACG usually develops in individuals older than 50 years.[1]

The size of the lens increases progressively with age, thus crowding the region of the anterior chamber angle, making it shallower.[25]

lens opacity

Cataractous lens is a risk factor for secondary angle-closure glaucoma (phacomorphic glaucoma).[26]

weak

family history of glaucoma

Most cases of angle-closure glaucoma are sporadic; however, there is an increased prevalence of angle closure in individuals with affected relatives.[1]​​[13][14][27]

use of drugs that induce angle narrowing

Sulfa-containing drugs (e.g., sulfonamides), diuretics (e.g., acetazolamide), topical pupil dilators (e.g., cyclopentolate, atropine), and anticonvulsants (e.g., topiramate) can precipitate ACG by pupillary block and displacement of the lens-iris diaphragm.[16][17]

corneal hysteresis

Refers to the corneal response to transient compression and release by an air-puff tonometer (i.e., the difference between the initial and rebound applanation pressure). Values may be lower in glaucoma, and lower values may be associated with an increased risk of glaucoma progression.[28]

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