Intended for healthcare professionals

Rapid response to:

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

Rapid Response:

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

Competing interests: No competing interests

05 December 2006
Paul R Brogden
Specialist Registrar in Ophthalmology
St James's University Hospital. Leeds LS9 7TF