Acute-angle glaucoma

• Eye pain (rapid onset) and frontal headache, vomiting, +/- blurred vision, haloes around lights. Reduced VA, hazy cornea, pupil oval/fixed

• In acute angle closure glaucoma, the conjunctiva would be generally red and the pupil would be fixed and mid-dilated. There is usually acute visual loss. Severe pain would have commenced rapidly. Nausea and vomiting are common.

• AACG more common in women and long-sighted individuals (hypermetropes). Typical examination findings include a mid-dilated pupil which is poorly reactive to light. AACG requires an emergency ophthalmological admission for further assessment including intraocular pressure measurement. Retinal detachment is more common in short-sighted individuals (myopes).

• Mydriasis (pupil dilation) can precipitate acute angle-closure glaucoma in a few patients over 60 years of age, with hypermetropia (long-sightedness). They are predisposed to the condition due to having a shallow anterior chamber.

• In any case of suspected AACG the management in primary care is immediate ophthalmology assessment. If immediate admission or assessment is not possible then the patient should lie flat and if available administer acetazolamide 500 mg orally with one drop of ocular pilocarpine (2% for blue eyes, 4% brown eyes).

Chronic open angle glaucoma

• Chronic simple glaucoma (or chronic open angle glaucoma) occurs when intra-ocular pressure is raised over months. There is no pain or redness to the eye. Examination reveals loss of visual fields and an enlarged, pale optic disc with cupping.

• Slow insidious loss of vision

• Eye drops are the preferred option, but are absorbed systemically. Timolol and carteolol are beta-blockers and can exacerbate bronchospasm.  Brimonidine, an adrenoceptor stimulant, can aggravate coronary insufficiency. Latanopost rarely causes chest pain or bronchospasm.

• Darkening, thickening and lengthening of eyelashes may occur with prostaglandin analogues and synthetic prostamides. These drugs can also cause an increase in brown pigment in the iris, making it appear darker – for this reason, drops should normally be inserted into both eyes, even if only one eye is affected. Corneal disorders have very rarely been reported with beta-blockers.

•  If a car and motorcycle license holder suffers from bilateral glaucoma, the DVLA must be notified.

Secondary glaucoma

• Causes include uveitis and eye trauma

Resources

• Glaucoma (CKS) / Glaucoma (Moorfields eye hospital)