• Glaucoma: visual field loss from optic neuropathy, commonly associated with raised IOP
• Angle-closure: contact between iris and trabecular meshwork (irido-trabecular contact) 
• Angle-closure glaucoma: irido-trabecular contact → raised IOP → optic neuropathy 

Acute presentation of angle closure glaucoma is an ophthalmic emergency. 

This section is based on NICE CKS. RCO Guidelines only applies to secondary and tertiary care.

Suspect acute angle closure glaucoma in:

• Sudden onset red painful eye
• Previous episodes of eye pain, blurred vision, headaches, nausea and seeing halos around light (indicates intermittent angle closure episodes that self resolved)
• Presence of a precipitating factor (e.g. in a dark room, use of antimuscarinic drug- Tricyclic antidepressant - Pupil dilating agent (mydriatic) , use of adrenergic druge.g. nasal decongestant that contains phenylephrine )

O/E:

• Red painful eye associated with headache, N&V 
• Hazy oedematous cornea 
• Semi-dilated fixed pupil (vertically oval shape)
• Tender hard eye 
• ↑ IOP

If acute angle closure glaucoma suspected → admit to ophthalmology immeidately

This section is based on RCO Guidelines. 

Definitive investigation: gonioscopy (uses a slit lamp and lens to visualise the iridocorneal angle)

Other supplementary investigations:

• Tonometry -  ↑ IOP
• Van Herick test - assessment of limbal anterior chamber depth (LAD)
• Anterior segment OCT 

This section is based on NICE CKS. RCO Guidelines only applies to secondary and tertiary care.

Refer immediately to be admitted under ophthalmology.

If immediate admission is not possible → start emergency treatment in primary care:

• Lie patient flat with face up, head not supported by pillow 
• Anti-emetic and analgesia if needed

 

• Pilocarpine eye drops 2% / 4% 2% in blue eyes, 4% in brown eyes
• Azatazolamide 500mg PO

This section is based on RCO Guidelines. 
 

• Analgesia and anti-emetics as needed
• Examination to confirm diagnosis + identify / exclude secondary causes

Stat medications:

• DorzolamideTopical carbonic anhydrase inhibitor 2% + timololTopical beta blocker 0.5% combined drops 
• ApraclonidineAlpha 2 agonist 0.5% drops 
• PilocarpineMuscarinic agonist 2% (if IOP >40 mmHg)
• IV acetazolamide 250mg (if IOP >40 mmHg)

Definitive management: laser peripheral iridotomy in both eyes

Management after peripheral iridotomy is completed:

• Steroid drops (dexamethasone 0.1% / prednisolone 1%)
• Minimum of hourly for 24 hours, then QDS for 1 week