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PRACTICE: Patel Gordon-Bennett, Tsiang Ung, Chris Stephenson, and Melanie Hingorani Misdiagnosis of angle closure glaucoma BMJ 2006; 333: 1157-1158 [Full text]

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Misdiagnosis of angle closure glaucoma - digital palpation can aid correct diagnosis.

Alexander C Day   (2 December 2006)

Is the lesson fair?

Jeremy E Oates   (4 December 2006)

Bedside Clinical Skills

Paul R Brogden   (5 December 2006)

Vomiting and glaucoma

A R Elkington   (6 December 2006)

Topiramate induced angle closure glaucoma

Branka Marjanovic, Adam Hustler   (11 December 2006)

Misdiagnosis of angle closure glaucoma - digital palpation can aid correct diagnosis. 2 December 2006
Alexander C Day, SpR Ophthalmology Chelsea and Westminster Hospital, 369 Fulham Road. London. SW10 9NH Send response to journal: Re: Misdiagnosis of angle closure glaucoma - digital palpation can aid correct diagnosis.	Lesson of the week, “Misdiagnosis of angle closure glaucoma,” highlights the difficulties that non-Ophthalmologists can face in making the correct diagnosis.[1] Without access to tonometry, intraocular pressure can be estimated by gentle digital palpation of the closed eye. In angle closure glaucoma the eye will feel much harder than if the intraocular pressure is normal.[2] Whilst this is a crude method, it is useful for identifying eyes with raised intraocular pressures.[3] [1] Gordon-Bennett P, Ung T, Stephenson C, Hingorani M. Lesson of the week: Misdiagnosis of angle closure glaucoma. BMJ, 2006. 333: 1157-1158. [2] Khaw, P.T., Shah, P. and Elkington, A.R. Glaucoma - 1: diagnosis. BMJ, 2004. 328: 97–99. [3] Baum J, Chaturvedi N, Netland PA, Dreyer EB. Assessment of intraocular pressure by palpation. Am J Ophthalmol. 1995. 119(5): 650-651. Competing interests: None declared
Is the lesson fair? 4 December 2006
Jeremy E Oates, Clinical research Fellow Hope Hospital, Salford. M6 8HD Send response to journal: Re: Is the lesson fair?	In the 'Lesson for the week', the authors cover an important issue that is particularly relevant to my own practice as a urological trainee due to its link with anti-cholinergic therapy. I do feel however that although there may be deficits in the care of the described patients, some of the judgements on the care seem harsh to say the least. In both case 1 and 2, the patients developed sudden onset, severe unilateral headache. Visual problems did not manifest in the second case till the day after admission. When faced with a patient complaining of sudden onset severe unilateral headache, it would be a brave clinician who did not arrange an "inappropriate computed tomography scan" or other "unnecessary investigations" to exclude intra-cranial pathology but instead to await specialist ophthalmological input, especially given that the authors recognise the difficulties in dealing with both patients due to poor history and lack of mobility. Interestingly, it would appear that the misdiagnosis of patient 2 was not made by the medical team who requested these "unnecessary investigations", but instead by the ophthalmologist whose opinion was sought due to suspicion of ophthalmic cause for her symptoms. It would seem that the main deficit in this lady's care came not from the medical teams lack of knowledge of acute angle glaucoma but instead from false reassurance from the reviewing ophthalmologist It is easy to criticise case management with the benefit of hindsight, but it should be remembered that cases are not so clear at the time of presentation as they are six months done the line when the case notes are reviewed, especially when in cases such as these, key signs and symptoms have not manifested at time of initial assessment. Competing interests: None declared
Bedside Clinical Skills 5 December 2006
Paul R Brogden, Specialist Registrar in Ophthalmology St James's University Hospital. Leeds LS9 7TF Send response to journal: Re: Bedside Clinical Skills	I congratulate Gordon-Bennett and co-authors1 for increasing the awareness of acute glaucoma as an often missed diagnosis when patients present to non-ophthalmic specialties. They state that diagnosis can often be delayed because of poor mobility and difficulty in positioning the patient on the slit-lamp. However it is important to stress that acute angle closure glaucoma can be quickly and correctly identified at the bedside. All that is required is a bright torch, a simple structured approach and a high index of clinical suspicion. In dim ambient lighting conditions, the bright light should be directed at the eye anteriorly. In cases of acute angle closure the cornea will appear cloudy rather than bright and shiny and the pupil will not react to light. Comparison with the fellow eye will be helpful. Then, by directing the light from a temporal position the “shadow test” will indicate that the anterior chamber is shallow if the temporal cornea is illuminated but the nasal half remains in darkness. Although the “shadow test” is not used as a population screening method for asymptomatic patients it can be very helpful in the acute situation when there is not easy access to a slit lamp2. As technology improves we will do well to remember that simple tests applied logically and sensibly remain the cornerstone of our assessment of the patient. 1. Gordon-Bennett P, Ung T, Stephenson C, Hingorani M. Misdiagnosis of angle closure glaucoma. BMJ 2006; 333: 1157-1158 2. Podolsky M. Exposing glaucoma. Primary care physicians are instrumental in early detection. Postgrad Med. 1998 May;103(5):131-6, 142- 3, 147-8. Competing interests: None declared
Vomiting and glaucoma 6 December 2006
A R Elkington, Emeritus Professor of Ophthalmology University of Southampton Send response to journal: Re: Vomiting and glaucoma	Dear Sir, Gordon-Bennett et al.,in their article 'Misdiagnosis of angle closure glaucoma', were right to include vomiting amongst the usual symptoms and to point out that the presentation may be 'more systemic than ocular'. I heard of an anaesthetist who diagnosed glaucoma when he checked the pupils of a patient undergoing a laparotomy for unexplained vomiting. The hapless surgeon realised, too late, that an iridectomy would have been the better intervention. A.R.Elkington, Emeritus Professor of Ophthalmology, University of Southampton. Competing interests: None declared
Topiramate induced angle closure glaucoma 11 December 2006
Branka Marjanovic, SPR Ophthalmology The Sussex Eye Hospital, Eastern Road, Brighton BN2 5BF, Adam Hustler Send response to journal: Re: Topiramate induced angle closure glaucoma	Dear Sir, I would agree with Gordon-Bennett et al. (1), that it is important to be aware that acute angle closure glaucoma can be participated by certain classes of drugs. In addition to anticholinergic agents, tricyclic antidepressants, selective serotonin reuptake inhibitors, and adrenergic agonists mentioned in their article 'Misdiagnosis of angle closure glaucoma' I would like to add that topiramate, an approved treatment for epilepsy and migraine prophylaxis can lead to severe attacks of bilateral angle closure glaucoma in young patients. Topiramate-induced angle-closure glaucoma (TiACG) is believed to be related to its sulfonamide moiety, although the exact mechanism is unknown (2). Patients starting topiramate therapy need to be informed of potential risks associated with its use, and the physicians should be aware that topiramate can lead to bilateral acute angle closure glaucoma in young patients. 1. Gordon-Bennett P, Ung T, Stephenson C, Hingorani M. Misdiagnosis of angle closure glaucoma. BMJ 2006; 333: 1157-1158 2. Rhee DJ, Ramos-Esteban JC, Nipper KS. Rapid resolution of topiramate-induced angle-closure glaucoma with methylprednisolone and mannitol. Am J Ophthalmol. 2006 Jun;141(6):1133-4. Competing interests: None declared