A 53 year old man presents with severe sudden onset pain in his left eye associated with nausea and cloudy vision. He describes seeing halos around lights. His symptoms started when he entered a dark nightclub where he was planning to celebrate New Year’s Eve.


What would you do next?

How would you treat this patient?

This patient likely has acute-angle closure glaucoma. Classic presentation is the rapid onset of headache, eye pain, and vomiting. Most patients do not have a history, but present following their first attack. They have a shallow anterior chamber, which predisposes them to getting angle closure.  The normal anterior chamber angle provides drainage for the aqueous humor. When this pathway is narrowed or closed, inadequate drainage of the aqueous humor leads to elevated intra-ocular pressure and damage to the optic nerve.

On exam, the patient has a fixed, mid-range, “steamy” pupil with significant amounts of cell and flare when viewed using a slit lamp. Cell is the visualization of cells in the anterior chamber, it appears as light reflecting off specks of dust in the air in a movie theater. Flare is light reflected off protein floating in the anterior chamber, appearing similar to light striking smoke.

Pressure monitoring with tonometry would likely demonstrate a pressure of 30 mmHg or higher (normal is 8- 21 mmHg).

Obtain emergent opthalmology consult to evaluate the patient and to discuss medication administration. Place the patient supine.

Further ED treatment consists of and administration of:

– Topical beta-blocker, such as timolol 0.5% to decrease aqueous humor production by the ciliary bodies

-Topical alpha-agonist, such as apraclonidine 0.1% to decrease aqueous humor production and increase trabecular outflow

– Topical steroid such as prednisolone 1% to decrease nerve injury from local inflammation

– Acetazolamide 500 mg IV or orally to further decrease aqueous humor production by acting on carbonic anhydrase

If extraocular pressure remains significantly elevated 30 minutes after giving the above medications, give mannitol 1-2 g/kg to further decrease intraocular pressure

In all patients, treat associated symptoms with analgesics and antiemetics as needed.