Ophthalmology Supp · Supplementary · from Ophthalmology Supp

Case 1: Acute Angle-Closure Glaucoma

Patient Presentation

Demographics: 62-year-old female retired schoolteacher

Chief Complaint: "My right eye suddenly became very painful and my vision went blurry about three hours ago."

History of Present Illness: The patient presents to the emergency department with acute onset of severe right eye pain, blurred vision, and seeing halos around lights that began approximately three hours ago while she was watching television in a dimly lit room. She describes the pain as a deep, aching sensation radiating to her right forehead and temple. She has experienced one episode of nausea and vomiting since symptom onset.

She denies any recent trauma to the eye, history of similar episodes, or recent eye surgery. She notes that she was prescribed new reading glasses six months ago and has noticed gradual difficulty with peripheral vision in both eyes over the past year. She took acetaminophen 1000 mg at home without relief.

She was recently started on a new medication by her primary care physician for urinary incontinence (oxybutynin), which she began taking five days ago. She has not had any recent ophthalmologic examination beyond her optometry visit for glasses.

Past Medical History:

• Hypertension, well controlled
• Overactive bladder syndrome
• Hyperopia (farsightedness) since age 40
• Osteoarthritis of the knees

Medications:

• Lisinopril 10 mg daily
• Oxybutynin 5 mg twice daily (started 5 days ago)
• Acetaminophen 500 mg as needed for joint pain
• Calcium with vitamin D supplement daily

Social History:

• Non-smoker
• Occasional glass of wine with dinner
• Lives with her husband, independent in all activities
• No occupational chemical or UV exposure

Family History:

• Mother had glaucoma diagnosed at age 70
• Father had type 2 diabetes and cataracts
• No family history of retinal detachment

Physical Examination

• Vital Signs: BP 158/94 mmHg, HR 92 bpm, RR 18/min, Temp 36.8°C, SpO2 98% on room air
• General: Alert, anxious-appearing woman in moderate distress, holding right side of her face
• Right Eye:
• Visual acuity: 20/200 (baseline 20/30 with correction)
• Conjunctival injection with ciliary flush
• Cornea: diffuse edema with microcystic changes, hazy appearance
• Anterior chamber: very shallow, Grade 0-1 by Van Herick technique
• Pupil: mid-dilated (6 mm), fixed, non-reactive to light, no afferent pupillary defect
• Iris: bowing forward (iris bombé configuration)
• Lens: mild nuclear sclerotic cataract
• Fundoscopy: limited due to corneal edema; optic disc difficult to visualize
• Intraocular pressure (IOP) by Goldmann applanation tonometry: 58 mmHg
• Left Eye:
• Visual acuity: 20/30 with correction
• Anterior chamber: shallow, Grade 1-2 by Van Herick technique
• Pupil: 3 mm, reactive
• IOP: 16 mmHg
• Fundoscopy: cup-to-disc ratio 0.4, healthy neuroretinal rim
• Gonioscopy (left eye): Narrow angles, Shaffer Grade 1-2 in all quadrants

Workup and Results

Laboratory Studies:

Imaging/Additional Studies:

• Anterior segment OCT (left eye): Confirmed narrow iridocorneal angle with anterior lens position
• Ultrasound biomicroscopy (when available): Plateau iris configuration suspected
• B-scan ultrasonography (right eye): No retinal detachment, no posterior segment mass; lens in normal position, axial length 21.2 mm (short, consistent with hyperopia)

Clinical Image

Diagram illustrating the pathophysiology of acute angle-closure glaucoma with pupillary block. Source: Educational illustration.

Diagnosis

Acute Primary Angle-Closure Glaucoma (Right Eye) with Narrow Angles (Left Eye)

Key Diagnostic Criteria:

• Acutely elevated IOP (58 mmHg) with symptoms of pain, blurred vision, halos, nausea/vomiting
• Shallow anterior chamber with closed angle on examination
• Mid-dilated, fixed pupil
• Corneal edema and conjunctival injection
• Precipitating factor: anticholinergic medication (oxybutynin)
• Anatomic predisposition: hyperopia, short axial length, shallow anterior chamber bilaterally

Treatment Plan

1. Immediate IOP-lowering therapy:

• Timolol 0.5% one drop to the right eye
• Apraclonidine 1% one drop to the right eye
• Pilocarpine 2% one drop to the right eye every 15 minutes x 2 doses (once IOP begins to fall below 40 mmHg and sphincter ischemia resolves)
• Acetazolamide 500 mg IV stat, followed by 250 mg PO every 6 hours
• Mannitol 1-2 g/kg IV over 45 minutes if IOP remains refractory

1. Topical prednisolone acetate 1% one drop every hour to reduce intraocular inflammation
2. Antiemetic: Ondansetron 4 mg IV for nausea
3. Discontinue oxybutynin immediately and notify prescribing physician
4. Definitive treatment: Laser peripheral iridotomy (LPI) to the right eye once corneal edema clears and IOP is controlled
5. Prophylactic LPI to the left eye given narrow angles and high risk of similar attack
6. Follow-up: Reassess IOP in 1 hour; ophthalmology admission if IOP uncontrolled; outpatient follow-up within 1 week post-LPI

Key Learning Points

• Anticholinergic medications (oxybutynin, antihistamines, tricyclic antidepressants, inhaled ipratropium) can precipitate acute angle-closure in anatomically predisposed eyes by causing pupillary dilation.
• Hyperopic (farsighted) patients have shorter axial lengths and shallower anterior chambers, placing them at higher risk for angle-closure glaucoma.
• The contralateral eye should always be examined and treated prophylactically with laser peripheral iridotomy, as the risk of a similar attack is approximately 50% within 5 years.
• Pilocarpine may be ineffective if the IOP is extremely high (>50 mmHg) because iris sphincter ischemia prevents miosis; it should be applied after initial IOP reduction with other agents.
• Acute angle-closure glaucoma is an ophthalmologic emergency; delay in treatment can result in permanent optic nerve damage and vision loss within hours.

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