Palpation of the glove reveals it to be hard. What is the SINGLE most likely visual symptom?

A 30 year old woman has a sudden acute headache with nausea and vomiting. She has a red, painful left eye. The symptoms started when she was watching television in a dark room. Palpation of the glove reveals it to be hard. What is the SINGLE most likely visual symptom?

A. Paracentral scotoma
B. Peripheral visual field loss
C. Coloured halos
D. Floaters
E. Glares

In acute angle closure glaucoma, coloured haloes around lights are often a complaint by patients. Nausea and vomiting are common and may be the main presenting feature in some patients.

Acute angle closure glaucoma

Also called acute glaucoma or narrow-angle glaucoma

In acute angle closure glaucoma (AACG) there is a rise in IOP secondary to an impairment of aqueous outflow. Factors predisposing to AACG include: - hypermetropia (long-sightedness) - pupillary dilatation

It presents with an eye that is red, severely painful,and associated with a semi-dilated non-reacting pupil. Headaches and decreased visual acuity are common. Symptoms worsen with mydriasis (e.g. watching TV in a dark room). Coloured haloes around lights may be seen by patients. Palpation of the globe will reveal it to be hard. Corneal oedema results in dull or hazy cornea. Systemic upset may be seen, such as nausea and vomiting and even abdominal pain.

Note: The acute attack is usually unilateral; however, long-term management will be to both eyes.

Medical Initial medical treatment typically involves all topical glaucoma medications that are not contra-indicated in the patient, together with intravenous acetazolamide.

Topical agents include: - Beta-blockers - eg, timolol, cautioned in asthma. - Steroids - prednisolone 15 every 15 minutes for an hour, then hourly - Pilocarpine 1-2% - Acetazolamide is given intravenously (500 mg over 10 minutes) and a further 250 mg slow-release tablet after one hour - Offer systemic analgesia ± antiemetics.

This should tide the patient over until they are able to be seen by a duty ophthalmologist who will assess the situation at short intervals until the acute attack is broken. These treatments may be repeated depending on the IOP response and a combination of these medications will be given to the patient on discharge. The patient will remain under close observation (eg, daily clinic reviews or as an inpatient). Subsequent treatment is aimed at specific mechanism of closure.


Peripheral iridotomy (PI) - This refers to (usually two) holes made in each iris with a laser. This is to provide a free-flow transit passage for the aqueous. Both eyes are treated, as

the fellow eye will be predisposed to an AAC attack too. This procedure can usually be carried out within a week of the acute attack, once corneal oedema has cleared enough to allow a good view of the iris.

Surgical iridectomy - This is carried out where PI is not possible. It is a less favoured option, as it is more invasive and therefore more prone to complications.