45 year-old female comes in with reduced vision for a day.

She complained of severe headache with

nausea and vomiting. VA was CF the conjunctiva was injected and was CF the conjunctiva was injected
and the cornea seems to be hazy. What do you have in mind and what do you think you have in mind
and what do you think you will check and do further?

I am thinking of an acute attack of angle closure glaucoma(ACG)

This involves the peripheral iris bowing forward obstructing aqueous access to the trabecular meshwork.
The sudden forward shift of the lens-iris diaphragm causes pupillary block and results in impaired
drainage, leading to a sudden rise in IOP.

Risk factors include being female and old age like in the scenario.

The clinical features of ACG include;

Symptoms

• Headache, nausea, vomiting (often mistaken for acute abdomen)

• Decreased vision

• Redness, lacrimation, photophobia

Signs

• Lid oedema

• Ciliary congestion

• Hazy, cloudy, insensitive cornea

• Shallow AC

• Mid-dilated vertically oval, non-reacting pupil

• Raised IOP (40-60mm Hg)

• VA- HM/ PL/PR

• Fundus- Not visualized due to corneal oedema

• Instillation of glycerine drop clears cornea

• Fundus- hyperemic disc, disc haemorrhage, arterial pulsation, no cupping

Therefore, the patient’s complaints(severe headache with nausea and vomiting; VA was CF; the injected
conjunctiva and the hazy cornea) all pointed to angle closure glaucoma.

I would check for the following;

 Intraocular pressure using Goldmann applanation tonometry (IOP>40mmHg is suggestive of

angle closure glaucoma)
  Anterior chamber depth using the Van Herick Method (Slit Lamp technique). Shallow AC is
suggestive of angle closure glaucoma)
 Pupillary light reflex; may reveal a mild-dilated vertically oval, non-reacting pupil
 Iris for abnormal blood vessels(rubeos iridis) using slit lamp examination since it could be a
precipitating factor

Management

Usually the IOP is >50 mm of Hg.

• Mannitol (20%) I.V 1.5-2 gm/kg body weight ( rapid drip) or Acetazolamide I.V 500 mg

• If the pupil is still blocked- press over central part of cornea with a sterile cotton bud to open the
peripheral block

• Oral glycerine (50%) with lemon juice TDS can be given

• Pilocarpine 2% drop is started after the IOP is reduced by Mannitol (in a very high IOP Pilocarpine can
not act on sphincter muscle as it becomes ischaemic)

• Beta blockers- BD Timolol maleate 0.5% Betoxolol 0.5

• Analgesic systemically

• Steroid drops to reduce congestions

• LASER treatment – once the IOP is reduced and eye becomes quite – YAG LASER peripheral iridotomy
is done

• Surgical treatment – if the medical and LASER treatment fails to control the IOP, then trabeculectomy
is done