Angle-closure: Diagnostics

• Sudden onset of symptoms

• Unilaterally inflamed, reddened, and severely painful eye (hard on palpation)

• Frontal headaches, vomiting, nausea

• Blurred vision and halos seen around light

• Cloudy cornea (opacification)

• Mid-dilated, irregular, unresponsive pupil

• Complications: rapid permanent vision loss due to ischemia and atrophy of the optic nerve

• Asymptomatic in early stages

• Progressive vision loss beginning with peripheral fields of vision (due to gradually increasing optic nerve compression)

Acute angle-closure glaucoma is vision-threatening and requires emergency ophthalmology evaluation as soon as the clinical diagnosis is suspected.

• Both eyes should be evaluated even if symptoms are unilateral. [11]

• A clinical diagnosis of angle-closure glaucoma is confirmed with the following findings:

  • Elevated IOP (> 21 mm Hg): on tonometry [6][13][14]

  • Narrowing/closure of the iridocorneal angle (i.e., iridotrabecular contact): on gonioscopy or slit-lamp examination

• Tests to assess for glaucomatous damage should be performed in all patients.

  • Optic disc changes (slit-lamp examination or undilated fundoscopy)

  • Visual acuity

  • Visual field testing

• Provocative testing (e.g., placing the patient in a dark room, administering mydriatics) is not recommended in acute angle-closure glaucoma because it is time-consuming, exacerbates symptoms, and is of questionable clinical significance. [6][11][13]

• Other causes of painful red eye (especially uveitis) and/or headache with ocular pain (e.g., migraine) should be considered if diagnostic findings are inconclusive.

Do not use mydriatic drugs (e.g., atropine and epinephrine) during ophthalmologic examination in patients with acute angle-closure glaucoma! Moreover, do not cover the eye, since darkness induces mydriasis and worsens the condition! [11]

• Indication: all patients with suspected glaucoma

• Procedure: measurement of IOP by placing a probe over the cornea .

• Characteristic findings

  • Acute angle-closure glaucoma: IOP is typically > 30 mm Hg

  • Chronic angle-closure glaucoma: IOP > 21 mm Hg

  • Angle-closure suspect: normal IOP

Gonioscopy

• Indications

  • Gold-standard test to assess the iridocorneal angle in suspected angle-closure glaucoma

  • To distinguish between primary and secondary causes of angle closure (see ''Pathophysiology'')

• Characteristic findings

  • Narrowing or closure of the iridocorneal angle (i.e., ≥ 180º iridotrabecular contact)

  • Etiology of narrowed/closed iridocorneal angle may be apparent

• Indication: to evaluate the anterior chamber and optic disc in all patients with suspected glaucoma

• Supportive findings

  • Acute and chronic angle-closure glaucoma: shallow anterior chamber

  • Acute angle-closure glaucoma

    • Cornea: cloudy or hazy

    • Pupil: mid-dilated (4–6 mm); sluggish pupillary reaction

  • Chronic angle-closure glaucoma: signs of glaucomatous optic neuropathy

    • Increased cup-to-disc ratio > 0.5

    • Asymmetrical cup-to-disc ratio between eyes

    • Superficial hemorrhages within the optic disc

    • Focal thinning and pallor of the neuroretinal rim

• Indication: an alternative to slit-lamp examination to assess for optic disc damage

• Supportive findings

  • Acute angle-closure glaucoma: edema and microhemorrhages of the optic disc with or without signs of glaucomatous optic neuropathy

  • Chronic angle-closure glaucoma: signs of glaucomatous optic neuropathy

Do not dilate the pupils to evaluate the fundus in suspected glaucoma!

• Indication: all patients with glaucoma

• Supportive findings

  • Acute angle-closure glaucoma: Corneal edema may decrease visual acuity even in the absence of glaucomatous optic neuropathy.

  • Chronic angle-closure glaucoma: There may be decreased central vision or complete blindness in advanced disease.

• Indication: all patients with glaucoma

• Techniques

  • Confrontation visual field exam: preferred in the ER when an ophthalmologist is not immediately available

  • Automatic static perimetry: preferred if an ophthalmologist is available

• Characteristic findings

  • Glaucomatous visual field defects: a characteristic pattern of visual field defects as a result of glaucomatous optic neuropathy

    • Early-stage: arcuate or double arcuate (ring) scotoma

      • Loss of peripheral vision especially of the superior and/or inferior hemifields

      • Sparing of central vision

    • Advanced stage

      • Tunnel vision: further constriction of peripheral vision

      • Total or near-total blindness: loss of peripheral and central vision with or without sparing of the temporal field