Acute angle closure crisis is an ophthalmic emergency caused by sudden rise in intraocular pressure due to blockage of aqueous outflow. It presents with severe eye pain, blurred vision, nausea and elevated eye pressure. Immediate treatment involves intravenous acetazolamide and topical eye drops to lower pressure. If pressure is not controlled, further interventions like laser iridotomy or surgery may be needed to relieve the block and prevent permanent vision loss from optic nerve damage. Long term management involves treatment of the underlying primary angle closure glaucoma with pressure lowering eye drops or surgery and monitoring for glaucoma progression.

1. Acute Angle
Closure Crisis
BY
DR SAFAA REFAAT
FRCSG, M.Sc., MBBS

2. Glaucoma
Definition:
 Glaucoma is a progressive optic neuropathy with
characteristic changes in the optic nerve head and
corresponding loss of VF.
 It represents a final common pathway for a number
of conditions, for most of which raised IOP is the
most important risk factor.
Increased
IOP
VF
Defect
ON
Cupping

3. Increased
IOP
VF
Defect
ON
Cupping

4. Classifications:
Etiology
Primary
Secondary
Anatomical
Open Angle
Closed Angle
Age of
onset
infantile
juvenile
Adult
onse
Clinical
Acute
Chronic

5. Anatomical Review

8. Primary angle-closure glaucoma
 PACG is a significant cause of blindness worldwide.
It is present in about 0.1% of the general population over
40y old.
 Acute angle closure crisis (AACC) is an ophthalmic
emergency.

9. Risk factors
Epidemiological
 Age: >40y old; mean age of diagnosis ± 60y.
 Female sex.
Ethnicity: Chinese, South East Asians.
Anatomical
 Pupil block mechanism
 Plateau iris mechanism

10. Pupil block mechanism
 Narrow angle, shallow AC,
 relatively anterior iris–lens diaphragm,
 large lens (older, cataract),
 short axial length (usually hypermetropic);
 risk increases with increasing lens thickness to axial length ratio.

11. In pupillary block,
apposition of the iris to the lens impedes aqueous
flow from PC to AC,
causing relative build-up of pressure behind the
iris, anterior bowing of the peripheral iris, and
subsequent angle closure.

12. Plateau iris mechanism
 Plateau iris configuration :
relatively anterior ciliary body that apposes the
peripheral iris to the trabeculum meshwork;
AC depth normal centrally, shallow
peripherally with flat iris plane.

13. Important Terminology:
 Acute angle closure Crisis (AACC): Irido-trabecular
contact ITC with acute symptomatic elevated IOP.
 Primary angle closure glaucoma (PACG): Primary angle
closure PAC with glaucomatous damage (changes in the
optic disc and VF).

14. Acute angle closure crisis
 Acute angle closure (AACC) is an ophthalmic emergency
requiring urgent treatment to prevent irreversible optic
nerve damage.
 Severe, permanent damage may occur within several
hours. If visual acuity is hand motions or worse, IOP
reduction is usually urgent
 Recurrent episodes of acute/subacute angle closure may
lead to synechial angle closure, and eventually to Primary
angle closure glaucoma (PACG)

15. Acute angle closure Crisis (AACC)
Clinical Picture;
symptoms:
 Pain (periocular pain , headache, abdominal
colic),
 Blurred vision, Haloes around the light.
 Nausea, vomiting.

16. Clinical Picture;
Signs:
 Red eye, Ciliary Congestion.
 Pupil; fixed semi-dilated,
 Visual Acuity may be as worse as HM
 Raised IOP (usually 50–80mmHg),
 Corneal oedema,
 Angle closed,
 Glaucomflecken;
 Contralateral angle narrow;
 Bilateral shallow AC.

17. Glaucomflecken

18.  Raised IOP (usually 50–80mmHg),
 Very important to learn how to check
IOP
 in ER:
Tonopen: simple portable contact
instrument for IOP Check
?? Digital Assessment: stony hard eye
globe
 Ophthalmologist use Goldman
Aplanation Tonometer

19. Differential diagnosis
Consider:
 secondry angle closure Glaucoma
(e.g.:
phacomorphic,
inflammatory,
neovascular)
 acute glaucoma Open Angle Glaucoma syndromes
(e.g.:
Posner–Schlossman syndrome or
Pigment Dispersion Syndrome)

20. Approach to the treatment of APAC
Immediate
 Systemic: Acetazolamide 500mg IV stat (then 250mg PO
4×/d).
 β-blocker (e.g. Timolol 0.5% Eye Drops stat, then every
12 hours).
 Sympathomimetic (e.g. Apraclonidine 1% ED stat).
 Steroid (e.g. Prednisolone 1% ED stat, then every 30 to 60
min.)
 Pilocarpine 2%ED (once IOP <50mmHg, e.g. twice in first
hour, then eye 6 hours).

21. Consider:
 Indentation Gonioscopy with a 4-mirror goniolens may help
relieve pupil block;
 lying the patient supine may allow the lens to fall back
away from the iris;
 Analgesics and Anti-emetics may be necessary.
 Pilocarpine 1% is often given to the contralateral eye
while awaiting Nd-YAG PI.

22. Intermediate
 Check IOP hourly until adequate control.
 If IOP not improving:
consider systemic Hyperosmotics (e.g.
Glycerol PO
Mannitol 20% 1g/kg of 50% solution in lemon juice or
solution IV 1–1.5g/kg).
 If IOP still not improving: consider acute Nd-YAG PI
(YAG Laser Peripheral Iridectomy)

23.  If IOP still not improving:
 Review the diagnosis
 Review the patency of PI or
proceed to surgical PI,
argon laser iridoplasty,
paracentesis,
cyclodiode photocoagulation,
or emergency cataract extraction/trabeculectomy.

24. Definitive Treatment
 Bilateral Nd-YAG or surgical
Peripheral Iridectomy.

25. Follow-Up
 After definitive treatment, patients are
reevaluated in weeks to months initially, and then
less frequently. Visual fields and stereo disc
photo- graphs are obtained for baseline
purposes.
 Follow Up: IOP, Optic Disc, Visual Field.
 Some eyes may develop chronic elevated IOP,
and will require long-term medical ± surgical
treatment.

26. Refrences:
 Oxoford Hand Book Of Ophthalmology, third edition, 2014
 Will’s Eye Manual, fifth edition 2008
 Preferred Practice Pattern, AAO, 2015.
 Photos copied from internet open sources.

27. THANK YOU