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Practice Lesson of the week

Misdiagnosis of angle closure glaucoma

BMJ 2006; 333 doi: (Published 30 November 2006) Cite this as: BMJ 2006;333:1157
  1. Patel Gordon-Bennett, senior house officer in ophthalmology,
  2. Tsiang Ung, specialist registrar in ophthalmology,
  3. Chris Stephenson, consultant ophthalmologist,
  4. Melanie Hingorani, consultant ophthalmologist
  1. 1Department of Ophthalmology, Hinchingbrooke Hospital, Huntingdon PE29 6NT
  1. Correspondence to: P Gordon-Bennett, Department of Ophthalmology, Princess Alexandra Hospital, Harlow CM20 1QX patelgordon{at}
  • Accepted 25 October 2006

Be suspicious for angle closure glaucoma in patients with headache, blurred vision, or red eye

Angle closure glaucoma is a sight threatening ophthalmic emergency. Patients classically present with an acutely painful red eye and periocular headache, loss of vision, nausea, and vomiting, but sometimes the presentation is less dramatic or more systemic than ocular. The diagnosis may be missed in such cases, leading to unnecessary investigations, delayed treatment, and blindness. We describe three cases of angle closure glaucoma in which initial diagnostic uncertainty led to a delay in treatment and which highlight the need for a wider awareness of this condition.

Case reports

Case 1

A 66 year old woman was admitted to the orthopaedic ward for elective spinal canal decompression for spinal stenosis. She was otherwise healthy and was taking oral diclofenac, morphine, and amitriptyline.

During the operation, she was placed prone for spinal laminectomy. Postoperatively, she received regular opiate analgesia. On the third postoperative day the patient developed severe headache, photophobia, and neck stiffness without focal neurological deficit. An urgent computed tomography scan of the head was normal.

On the fourth postoperative day she complained of visual loss, a red eye was noted, and an ophthalmology referral was made. Her visual acuity was counting fingers for both eyes. Slit lamp examination was hampered by her immobility, but both eyes were red with cloudy corneas; shallow anterior chambers; fixed, mid-dilated pupils; and high intraocular pressures of 45 mm Hg in the right eye and 33 mm Hg in the left eye (normal <21 mm Hg). A diagnosis of bilateral angle closure glaucoma was made.

She was treated immediately with the standard medical regimen …

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