History and exam

Key diagnostic factors

common

halos around lights

Present in the acute and subacute forms but not with the chronic form of angle closure.

aching eye or brow pain

Present in the acute and subacute forms but not with the chronic form of angle closure.

headache

A deep, dull, periocular ache may be present in the acute and subacute forms but not with the chronic form of angle closure.

nausea, vomiting

Present in the acute and subacute forms but not with the chronic form of angle closure.

reduced visual acuity

Present in the acute and subacute forms but usually not with the chronic form of angle closure.

eye redness

Present in the acute and subacute forms but not with the chronic form of angle closure.

elevated intraocular pressure (IOP)

In healthy eyes, IOP is generally 10 to 21 mmHg. In acute attacks, IOP rises rapidly to relatively high levels, typically above 40 mmHg. In chronic ACG, the IOP may be variably elevated depending on the extent of angle closure.

corneal edema

Present in the acute and subacute forms but not with the chronic form of angle closure.

fixed dilated pupil

Iris ischemia may cause the pupil to remain permanently fixed and dilated.

Present in the acute and subacute forms but not with the chronic form of angle closure.

Other diagnostic factors

common

use of medications that induce angle narrowing

Anticholinergic topical pupil dilators (e.g., cyclopentolate or atropine) or systemic medication (e.g., sulfonamides, topiramate, phenothiazines).

incidental eye findings

In chronic disease, most patients are asymptomatic and ACG is incidentally detected as part of an ophthalmic examination.

blurred vision

Present in the acute and subacute forms but not with the chronic form of angle closure.

corneal hysteresis

Generally low in glaucoma. Lower values may be associated with an increased risk of glaucoma progression.[28]​

uncommon

change in vision

In effect this is new recognition of longstanding chronic progressive visual field loss.

Risk factors

strong

female sex

Women are at increased risk of ACG compared to men.[16]

The exact reason for this has not been elucidated, but is likely due to a combination of biological and socioeconomic factors. Some experts believe that sex hormones in premenopausal women confer a protective effect that is then lost once women enter the menopause.[16]

hyperopia

The anterior chamber depth and volume are smaller in hyperopic eyes (farsighted).[11][19][20]

shallow peripheral anterior chamber

Having smaller anterior segment dimensions is the main ocular risk factor for closure of the angle, with anterior chamber depth having the strongest correlation with angle closure and ACG.[21][22]

second eye having angle closure

Anatomic factors of both eyes are virtually always similar. An untreated fellow eye has a 40% to 80% chance of developing an acute episode of angle closure over the next 5 to 10 years.[17][23][24]

Inuit and Asian ethnicity

Highest rates of ACG are reported in Inuit and Asian populations.[10][11][12][13]

advanced age

ACG usually develops in individuals older than 50 years.[17]

The size of the lens increases progressively with age, thus crowding the region of the anterior chamber angle, making it shallower.[25]

weak

family history

Most cases of ACG are sporadic; however, there is an increased prevalence of angle closure in individuals with affected relatives.[17][26]

use of medications that induce angle narrowing

Anticholinergic topical pupil dilators (e.g., cyclopentolate or atropine) or systemic medication (e.g., sulfonamides, topiramate, phenothiazines).[27]

corneal hysteresis

Corneal hysteresis refers to the corneal response to transient compression and release by an air-puff tonometer (i.e., the difference between the initial and rebound applanation pressure). Values may be lower in glaucoma, and lower values may be associated with an increased risk of glaucoma progression.[28]​

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