Angle-closure glaucoma

Last reviewed: July 2019

Last updated: July 2019

Summary

Acute angle-closure glaucoma is an urgent but uncommon, dramatic symptomatic event with blurring of vision, painful red eye, headache, nausea, and vomiting.

Diagnosis is made by noting high intra-ocular pressure, corneal oedema, shallow anterior chamber, and a closed angle on gonioscopy.

Medical or surgical therapy is directed at widening the angle and preventing further angle closure.

If glaucoma has developed it is treated with therapies to lower intra-ocular pressure.

Chronic angle-closure glaucoma is diagnosed by noting peripheral anterior synechiae on gonioscopy, as well as progressive damage to the optic nerve and characteristic visual field loss. It is treated with therapies to lower intra-ocular pressure.

Definition

Angle-closure glaucoma (ACG) is a group of diseases in which there is reversible (appositional) or adhesional (synechial) closure of the anterior-chamber angle resulting in elevation of the intra-ocular pressure (IOP). The angle closure may occur in an acute or chronic form. In the acute form, the IOP rises rapidly as a result of relatively sudden blockage of the trabecular meshwork by the iris, via the pupillary block mechanism (mechanism that pushes iris from behind leading to angle closure). The chronic form may develop after acute angle closure where synechial closure of the angle persists. It may also develop over time, as the angle closes from prolonged or repeated contact between the peripheral iris and the trabecular meshwork, which often leads to peripheral anterior synechiae (PAS) and functional damage to the angle.

History and exam

Key diagnostic factors

presence of risk factors
halos around lights
aching eye or brow pain
headache
nausea, vomiting
reduced visual acuity
eye redness
elevated intraocular pressure (IOP)
corneal oedema
fixed dilated pupil

Full details

Other diagnostic factors

incidental eye findings
blurred vision
change in vision

Full details

Risk factors

female sex
hyperopia
shallow peripheral anterior chamber
second eye having angle closure
Inuit and Asian ethnicity
advanced age
family history
use of medications that induce angle narrowing

Full details

Diagnostic investigations

1st investigations to order

gonioscopy, examination of anterior chamber angle
slit-lamp examination
automatic static perimetry

Full details

Investigations to consider

ultrasound biomicroscopy
anterior segment optical coherence tomography (of angle)
evaluation of the optic nerve head by fundoscopy
retinal optical coherence tomography
Heidelberg's retinal tomography
GDx nerve fibre analyser

Full details

Treatment algorithm

ACUTE

initial presentation: acute angle-closure glaucoma

initial presentation: chronic angle-closure glaucoma

ONGOING

residual angle closure after laser peripheral iridotomy with elevated intra-ocular pressure

repeat episode of acute angle-closure glaucoma

Contributors

Authors VIEW ALL 

Ani Khondkaryan, MD

Associate Clinical Professor

Department of Ophthalmology

Keck School of Medicine

University of Southern California

Los Angeles

Disclosures

AK declares that she has no competing interests.

Brian A. Francis, MD, MS

Riffenburgh Professorship in Glaucoma

Associate Professor of Ophthalmology

Doheny Eye Institute

Department of Ophthalmology

Keck School of Medicine

University of Southern California

Los Angeles

Disclosures

BAF is a consultant for Diopsys, Endo Optiks, Glaukos, NeoMedix, and Bausch Health. BAF is a speaker for Bausch + Lomb, and has given expert opinion to Valentine Law Group and Reback, McAndrews, Kjar, Warford & Stockalper, LLP.

Acknowledgements

Dr Ani Khondkaryan and Dr Brian A. Francis would like to gratefully acknowledge Dr Yaniv Barkana and Dr Noa Chetrit, previous contributors to this topic. YB and NC declare that they have no competing interests.

Peer reviewers VIEW ALL 

Gus Gazzard, MA, MBBChir, MD, FRCOphth

Consultant Ophthalmic Surgeon

King's College Hospital

Honorary Research Fellow

Institute of Ophthalmology

London

Disclosures

GG declares that he has no competing interests.

Edward J. Rockwood, MD

Associate Professor of Ophthalmology

Cleveland Clinic Lerner College of Medicine of Case Western Reserve University

Cole Eye Institute

Cleveland Clinic

Cleveland

Disclosures

EJR has received one honorarium from Pfizer, Inc. (manufacturers of Xalatan) for a speaking engagement.

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Angle-closure glaucoma

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

initial presentation: acute angle-closure glaucoma

initial presentation: chronic angle-closure glaucoma

residual angle closure after laser peripheral iridotomy with elevated intra-ocular pressure

repeat episode of acute angle-closure glaucoma

Contributors

Authors VIEW ALL 

Ani Khondkaryan, MD

Disclosures

Brian A. Francis, MD, MS

Disclosures

Acknowledgements

Peer reviewers VIEW ALL 

Gus Gazzard, MA, MBBChir, MD, FRCOphth

Disclosures

Edward J. Rockwood, MD

Disclosures

Differentials

Guidelines

Patient leaflets

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