1. Primary angle-closure glaucoma
Sartaj Sandhu

2. Outline Case study: Mrs. LH Glaucoma: a sight-threatening condition
Who is at risk?
How can glaucoma present to ED?
Diagnosis and treatment
Outcomes and disposition

3. Case study: Mrs. LH Presenting complaint
52 years old female of Asian b/g
p/w sudden onset RIGHT eyebrow pain/headache, blurred vision, nausea and vomiting
Further history – halos around lights, symptoms began 2 hours ago after she watched a movie in a cinema
NB. No trauma/flashes/floaters/diplopia/metamorphopsia/amaurosis fugax

4. Case study: Mrs. LH History
POHx – no surgery, laser, injection or other treatment; wears glasses for reading
PMHx – LBP, healthy otherwise, previous appendicectomy
FHx – grandmother ?blind in one eye, otherwise nil Glauc/MD/RD/DM/IHD/HTN
SHx – smoker (upto 15/day); EtOH on special occasions, Admin-worker
Meds – Panadeine forte PRN, NKDA

5. Case study: Mrs. LH Examination
RVA 6/60, NIPH, LVA 6/6
IOP RE = 56 mmHg, LE = 15
Pupils – RIGHT mid-dilated, sluggishly responsive to light, LEFT normal
Visual fields NAD bilaterally
Slit lamp exam – RE: injected conj, corneal oedema, shallow AC, ‘Iris bombe’, gonioscopy – closed angle on LE

6. Glaucoma
“a group of disorders leading to optic neuropathy, often chronic and associated with a high intraocular pressure”
Primary angle-closure glaucoma
Accountable for up to 50% of
all Glaucoma cases worldwide

7. Primary angle-closure glaucoma Who is at risk?
Asian or Inuit descent
Hyperopes
Female
Age (most common between 55 and 65)
“Screening has a role, especially in adults > 40 years old and is done with a gonioscope”

8. Pathophysiology
Occlusion of the trabecular meshwork by the peripheral iris
Can be seconday/drug-induced
Two types of closure  IOP rise
Appositional
Synechial
Glaucomatous changes in optic nerve  visual field loss  blindness

9. Diagnosis Diagnosis based on clinical findings
?role for provocation testing
Pen-light test
Van Herick staging
Gonioscopy findings (both eyes)

10. Treatment Guiding principles Reduce IOP
Open the outflow tract for the aqueous humour
Prevent/treat inflammation
Treat any symptoms

11. Medical treatment I Urgent referral to Ophthalmology team
Hospital admission
Supine position
IV Acetazolamide 500 mg +/- PO (if IOP >50)
PO Acetazolamide 500 mg (if IOP <50)
Anti-glaucoma drops e.g. timolol 0.5%

12. Medical treatment II Steroid drops e.g. prednisolone 1%
+/- Pilocarpine 1-2% (beware of pupillary sphincter ischaemia)
Analgesia and anti-emetic PRN
Mannitol 20% 1-2g/kg IV over 1 hr; others incl glycerol and isosorbide

13. Surgical treatment Surgical treatment (Corneal indentation)
Anterior chamber paracentesis
Laser peripheral iridotomy or iridoplasty (need to clear corneal oedema first)
Others include peripheral iridectomy, lens extraction, goniosynechialysis, trabeculectomy and cyclodiode laser

14. Differential diagnoses
Other causes of headache/vomiting

15. Complications
Fellow eye attack (can be up to 80% change within 5-10 years)
Consider prophylactic laser PI
Permanent decrease in VA
Endothelial dysfunction in cornea
‘Decompression retinopathy’
Ischaemia of the optic nerve
Loss of vision

16. Emergency pearls
Acute, atraumatic eye pain or decreased visual acuity – need to r/o PACG
Headache and vomiting – need to r/o PACG
Always check the unaffected eye – will have a shallow AC
Beware when dilating patient’s eyes – as iatrogenic PACG can occur in susceptible individuals
Pilocarpine may be ineffective above IOP of and after ‘hours’ have passed

17. Thank you