Thanks to Dr. Yeo for today’s Morning Report on Acute Angle-Closure Glaucoma!
Acute Angle-Closure Glaucoma
Introduction:
Ocular emergency caused by sudden/increase in IOP
Prolonged increased IOP may lead to optic nerve damage and irreversible blindness
Iris is pushed or pulled anteriorly to block trabecular meshwork, blocking outflow of aqueous, leading to increased IOP
Less than 10% of glaucoma cases in the US are due to AACG
Asians and Eskimos have anatomically narrower angles
AACG occurs in 1 of 1000 whites, about 1 in 100 Asians, and as many as 2-4 of 100 Eskimos
In white patients, AACG 3x higher in women than men
In black patients, women and men affected equally
Clinical Presentation
Dramatic symptoms: periorbital pain, blurry vision, associated ipsilateral headache, halos around objects, nausea/vomiting
Physical exam: corneal/scleral injection and ciliary flush, pain on eye movement, mid-dilated nonreactive pupil, firm globe
IOP > 21mmHG (normal 10-20mmHg)
Differential Diagnosis
Cataracts, conjunctivitis, chronic angle closure glaucoma, migraines
Management in the ED
Check visual acuity, external eye, visual fields, fundoscopic exam, pupils, ocular motility, and IOP
Topical B-blocker (i.e. timoptic), one drop
Topical a-agonist (i.e. Iopidine), one drop
Topical steroid (i.e. Predforte), one drop q15min x4, then hourly
Carbonic anhydrase inhibitor 500mg IV or PO
Mannitol 1 to 2g/kg IV
Recheck IOP hourly
Topical pilocarpine one drop 4x daily until IOP <40
Ophtho consult
Definitive treatment: peripheral laser iridectomy
TONO-PEN INSTRUCTIONS
Calibration:
- Apply probe tip cover
- Point tip downwards to the floor
- Press OPERATOR BUTTON two times fast. The pen will beep and display [CAL]
- Wait 15 seconds, the pen will beep and [CAL] will change to [UP]
- Turn the pen up, the pen will display [Good] and then beep
- Repeat if [bAd] is displayed
- After [Good] is displayed, press OPERATOR BUTTON once and the pen will display [8.8.8.8] then [—-] then [====] then beep, the pen is ready
Taking a Measurement:
- Topically anesthetize the eye
- Position patient seated or supine
- Instruct patient to look straight ahead at a fixed target
- Hold pen like a pencil
- Brace heel of hand onto cheek for stability
- Press OPERATOR BUTTON, initially you will see [8.8.8.8] then [====] then beep
- Touch pen to cornea lightly and briefly, repeat several times
- A chirp will sound and measurement will be displayed each contact
- After 4 valid readings are obtained, final beep will sound and averaged IOP will appear
*The pen also measures statistical reliability, under the LCD screen are four percentages (>20, 20, 10, 5). A bar will appear after the averaged IOP measurement indicating the statistical reliability of the four readings. 5% is good. 20% or greater means you should repeat the measurement of IOP.
Thanks for reading, leave any comments below!
Jay Khadpe MD
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