Intended for healthcare professionals

Rapid response to:

Clinical Review

Subarachnoid haemorrhage

BMJ 2006; 333 doi: (Published 27 July 2006) Cite this as: BMJ 2006;333:235

Rapid Response:

Acute glaucoma - another cause for severe headache and misdiagnosis in clinical practice

Editor - The review by Al-Shahi et al (1) gives a comprehensive
overview of subarachnoid haemorrhage and provides an ideal opportunity to
remind colleagues that acute angle-closure glaucoma should enter the
differential diagnosis in any patient presenting with acute severe
headache and nausea, vomiting or photophobia.

I have seen several patients, across NHS trusts, with acute glaucoma
referred late to the ophthalmology service after having undergone
unnecessary investigations such as computed tomography scan (CT) of the
brain, despite having characteristic signs such as red eye, hazy cornea,
mid-dilated pupil and decreased vision. Whilst tonometry (measurement of
the intraocular pressure) confirms the diagnosis, one can have a high
degree of suspicion even before this is performed. Importantly, delayed
recognition and onward referral inevitably delays appropriate treatment
and so negatively impacts on the final visual outcome. Whilst much seen
anecdotaly and despite discussion at grand rounds and teaching sessions,
the misdiagnosis or delayed diagnosis of acute glaucoma remains an ongoing
issue in clinical practice.

Thus, attending clinicians should look for the constellation of
clinical signs described above in all patients presenting with severe
headache, particularly if the pain is peri-orbital. If a CT scan of the
brain is normal, one must have a high index of suspicion for acute
glaucoma and perform an ophthalmic and pupil examination, particularly if
this was initially omitted. Finally, the availability, and consequent use,
of manual or digital handheld tonometers in emergency departments may
provide a practical means of promptly confirming or excluding what
constitutes an ophthalmic emergency.

1. Al-Shahi R, White PM, Davenport RJ, Lindsay KW. BMJ 2006;333:325-

Competing interests:
None declared

Competing interests: No competing interests

28 July 2006
Hiten G. Sheth
Specialist Registrar, Ophthalmology
North Middlesex University Hospital, London N18 1QX