Education And Debate

Lesson of the Week: Acute angle closure glaucoma masquerading as systemic illness

BMJ 1996; 313 doi: https://doi.org/10.1136/bmj.313.7054.413 (Published 17 August 1996) Cite this as: BMJ 1996;313:413
  1. Margaret Dayan, registrar in ophthalmologya,
  2. Benjamin Turner, senior house officer in ophthalmologya,
  3. Charles McGhee, consultant ophthalmologistb
  1. aSunderland Eye Infirmary, Sunderland SR2 9HP
  2. bUniversity of Sunderland School of Health Sciences, Sunderland SR2 7EE
  1. Correspondence to: Miss M Dayan, Department of Ophthalmology, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP.
  • Accepted 24 May 1996

Acute angle closure glaucoma is a comparatively rare, acute form of glaucoma that may be associated with various systemic symptoms; these can overshadow the primary ocular problem. In some cases this delay in diagnosis may result in blindness. We report on three women who presented to our department with acute angle closure glaucoma during one fortnight. Their initial symptoms were attributed to surgical and psychiatric problems rather than to their ocular disease.

Acute angle closure glaucoma can present with systemic symptoms such as headache or gastrointestinal disturbance

Case reports CASE 1

A 63 year old hypermetropic (long sighted) woman presented to her general practitioner with a 24 hour history of right sided headache followed, several hours later, by vomiting, diarrhoea, and non-specific abdominal pain. Her symptoms failed to settle and she was referred to hospital and admitted under a surgical team. No cause could be found for her gastrointestinal disturbance, but the following day her right eye was noted to be red; on direct questioning she admitted to a reduction in visual acuity in that eye, which had coincided with the onset of her symptoms. She was referred to the eye accident and emergency department.

The visual acuity in her right eye was reduced to hand movements and associated with a raised intraocular pressure of 44 mm Hg (normal range 10-21 mm Hg), a fixed, mid-dilated pupil, substantial corneal oedema, and a very shallow anterior chamber. Angle closure glaucoma was diagnosed and the intraocular pressure lowered medically. Her systemic symptoms resolved completely. Bilateral laser peripheral iridotomies were performed on the next day. Her visual acuity improved to 6/12 in the right eye compared with 6/6 in the left. A visual field examination gave normal results six weeks later.

CASE 2

A 63 year old hypermetropic woman was given amitriptyline 25 mg once daily by her general practitioner for symptoms of depression, including fatigue and insomnia. Soon afterwards she developed recurrent evening headaches accompanied by mild blurring of vision, which, she later admitted, were also associated with seeing coloured haloes around bright lights. These symptoms entirely resolved with sleep and were attributed to her depression. Consequently, the dose of amitriptyline was increased to 100 mg at night, with a concurrent increase in the frequency of her symptoms. A month later she developed persistent headache and blurring of vision in the right eye, for which she attended the eye accident and emergency department.

On examination the visual acuity in her right eye was reduced to 6/9 (compared with 6/5 on the left). This was associated with a substantially raised intraocular pressure of 60 mm Hg, a fixed, mid-dilated pupil, moderate corneal oedema, and a very shallow anterior chamber. Acute on intermittent angle closure glaucoma, precipitated by amitriptyline, was diagnosed. The intraocular pressure in the right eye was lowered medically. Bilateral laser peripheral iridotomies were performed on the same day. The visual acuity in her right eye remained at 6/9 and visual field examination showed that the visual field was constricted on the right.

CASE 3

A 59 year old hypermetropic woman presented to her general practitioner with a four week history of intermittent frontal headaches that occurred mainly in the evening. These were associated with a one year history of episodes of blurred vision in both eyes. She had recently been bereaved and had poor appetite and bouts of tearfulness: she was given dothiepin hydrochloride 75 mg at night for what was presumed to be depression. Two weeks later her vision became blurred and her eyes red and painful. Her symptoms persisted despite treatment with chloramphenicol drops, and she developed a severe frontal headache with vomiting. She was referred to the eye accident and emergency department three days later.

On examination her visual acuities were reduced to 6/24 bilaterally in association with raised intraocular pressures of 62 mm Hg in both eyes, fixed mid-dilated pupils, bilateral corneal oedema, and shallow anterior chambers. Acute on intermittent angle closure glaucoma, precipitated by dothiepin hydrochloride, was diagnosed. The intraocular pressures were lowered medically and bilateral laser peripheral iridotomies performed the next day. Her visual acuities improved to 6/9 bilaterally, and examination showed that her visual fields were full.

Discussion

The incidence of acute angle closure glaucoma in Britain is about 1 in 1000 people over the age of 40, with a female to male ratio of 4:1.1 It is commoner in short, usually hypermetropic, eyes that have a shallow anterior chamber and narrow iridocorneal angle.2 The initiating factor in angle closure is the development of pupillary block. This is caused by contact between the iris in a semidilated pupil and the lens, resulting in blockage of the flow of aqueous humour from its site of production in the ciliary body, through the pupil, into the anterior chamber. The build up of aqueous humour in the posterior chamber results in forward bowing of the iris, which then closes the already narrow iridocorneal drainage angle, producing a rise in intraocular pressure.1 3 A persistent increase in the intraocular pressure will result in a progressive and irreversible loss of vision. A delay in the start of treatment may result in permanent visual loss and even blindness.

Acute angle closure can be precipitated in an anatomically predisposed eye by physiological pupillary semidilation, such as occurs in the evening or when watching television in a darkened room. Pharmacological dilation with 1% tropicamide, used routinely in the assessment of diabetic retinopathy, rarely results in pupil block, but in diabetes the iris may spontaneously half dilate rather than fully dilate owing to autonomic neuropathy. This probably explains the increased risk of angle closure glaucoma in diabetic patients.4 Various drugs—most commonly those with anticholinergic properties, such as the tricyclic antidepressents5 prescribed in cases 2 and 3, nebulised ipratropium bromide,6 7 and nebulised atropine8—have also been reported to precipitate angle closure glaucoma. Complete angle closure may be preceded by intermittent episodes of partial or temporary closure of the angle,3 which are terminated by pupil constriction induced by bright light or sleep. Between episodes, however, the eye looks perfectly healthy and the diagnosis must be based on a history of evening headaches associated with blurred vision and haloes around lights (due to the presence of corneal oedema) as in case 2, coupled with the presence of a shallow anterior chamber on slit lamp biomicroscopic examination. Patients with such symptoms should have a careful review of their drug treatment and be referred for an early ophthalmological opinion as they will require laser peripheral iridotomies to prevent the development of acute angle closure glaucoma. Only half of the patients presenting with acute angle closure glaucoma, however, have a history of such intermittent preceding symptoms.1

Patients with acute, prolonged closure of the iridocorneal angle may present not only with reduced visual acuity, pain, and redness of the affected eye but also with systemic symptoms such as headache, malaise, and vomiting. In some cases, and particularly in elderly people, the systemic disturbance may be so severe that the ocular symptoms are initially overlooked, as happened in case 1, and the patient may be misdiagnosed as having an acute medical or, as in this case, surgical condition. On examination the visual acuity will be reduced in a red eye which may feel hard to the touch, with a cloudy cornea and a fixed, mid-dilated pupil (fig 1). These patients require urgent ophthalmological referral for immediate medical treatment to lower the intraocular pressure, followed by definitive bilateral laser or surgical procedures. After iridotomy, iridectomy, or trabeculectomy it is safe to dilate these patients' pupils and to start treatment with anticholinergic drugs once more.

Fig 1
Fig 1

Typical appearance of acute angle closure glaucoma in right eye: note conjunctival injection, corneal oedema, and mid-dilated pupil. Reproduced with patient's permission

The diagnosis of acute angle closure glaucoma in a patient who presents with the sudden onset of a painful, red eye with reduced visual acuity, a hazy cornea, and a fixed semidilated pupil is comparatively straightforward. But any patient with headache, malaise, or gastrointestinal disturbance and a red eye should alert doctors to the possibility of closed angle glaucoma. This is especially important in elderly people, who may not volunteer any specific ocular symptoms.

Reference

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